DAQ-2024-004318

1

DAQC-1327-23
Site ID 12524 (B5)

MEMORANDUM

TO: CEM FILE – PACIFICORP – Currant Creek Power Plant

THROUGH: Harold Burge, Major Source Compliance Section Manager

FROM: Rob Leishman, Environmental Scientist

DATE: December 8, 2023

SUBJECT: Source: Units CTG1A and CTG1B
Contact: Erik Ricardo – 435-623-3816
Tom Wiscomb – 801-220-2373
Location: West 300 North, Mona, Juab County, UT
Test Contractor: Montrose Air Quality Services, LLC
FRS ID#: UT00000049002300026
Permit/AO#: AO DAQE-AN-1252400009-15 dated January 23, 2015
Subject: Review of RA/PST Protocol dated December 4, 2023

On December 4, 2023, Utah Division of Air Quality (DAQ) received an emailed protocol for a RA/PST
(relative accuracy/performance specification test) of the Pacificorp Currant Creek Units CTG1A and
CTG1B in Mona, Utah. Testing will be performed on January 30-31, 2024, to determine the relative
accuracy of the NOX and CO monitoring systems.

PROTOCOL CONDITIONS:

1. RM 3A used to determine dry molecular weight of the gas stream; OK
2. RM 7E used to determine NOX concentrations of emissions; OK
3. RM 10 used to determine CO concentrations of emissions; OK
4. RM 19 used to determine volumetric flow; OK
DEVIATIONS: No deviations noted.

CONCLUSION: The protocol appears to be acceptable.

RECOMMENDATION: Send attached protocol review and test date confirmation notice.

1 8 2

Source Test Plan
2024 Compliance and RATA Testing
CTG1A, CTG1B
PacifiCorp
Currant Creek Generating Station
Mona, UT
Prepared For:
PacifiCorp
1407 W North Temple, Suite 210
Salt Lake City, Utah 84116
Prepared By:
Montrose Air Quality Services, LLC
990 West 43rd Avenue
Denver, CO 80211
For Submission To:
Utah Department of Environmental Quality, Division of Air Quality
195 North 1950 West
Salt Lake City, UT 84116
Document Number: 043AS-022762-PP-770
Proposed Test Dates: January 30 & 31, 2024
Submittal Date: December 30, 2023

Review and Certification
I certify that, to the best of my knowledge, the information contained in this document is
complete and accurate and conforms to the requirements of the Montrose Quality
Management System and ASTM D7036-04.
Signature: Date: 12/1/2023
Name: Matthew Parks Title: QA/QC Analyst
I have reviewed, technically and editorially, details and other appropriate written materials
contained herein. I hereby certify that to the best of my knowledge the presented material
is authentic and accurate and conforms to the requirements of the Montrose Quality
Management System and ASTM D7036-04.
Signature: Date: 12/1/2023
Name: Tim Wojtach Title: Account Manager

GP043AS-022762-PP-770 Page 2 of 46
Table of Contents
Section Page
1.0 Introduction ........................................................................................................ 5
1.1 Summary of Test Program ............................................................................. 5
1.2 Applicable Regulations and Emission Limits ...................................................... 6
1.3 Key Personnel .............................................................................................. 7
2.0 Plant and Sampling Location Descriptions................................................................ 8
2.1 Process Description, Operation, and Control Equipment ..................................... 8
2.2 CEMS Description ......................................................................................... 8
2.3 Flue Gas Sampling Locations .......................................................................... 9
2.4 Operating Conditions and Process Data ........................................................... 9
2.5 Plant Safety ................................................................................................. 9
2.5.1 Safety Responsibilities .......................................................................... 9
2.5.2 Safety Program and Requirements ....................................................... 11
3.0 Sampling and Analytical Procedures ..................................................................... 12
3.1 Test Methods ............................................................................................. 12
3.1.1 EPA Methods 3A, 6C, 7E, and 10 .......................................................... 12
3.1.2 EPA Method 201A ............................................................................... 13
3.1.3 EPA Method 202 ................................................................................. 13
3.2 Process Test Methods .................................................................................. 15
4.0 Quality Assurance and Reporting .......................................................................... 16
4.1 QA Audits .................................................................................................. 16
4.2 Quality Control Procedures .......................................................................... 16
4.2.1 Equipment Inspection and Maintenance ................................................ 16
4.2.2 Audit Samples ................................................................................... 16
4.3 Data Analysis and Validation ........................................................................ 16
4.4 Sample Identification and Custody ................................................................ 17
4.5 Quality Statement ...................................................................................... 17
4.6 Reporting .................................................................................................. 17
4.6.1 Example Report Format ...................................................................... 18
4.6.2 Example Presentation of Test Results ................................................... 18
List of Appendices
Appendix A Supporting Information ........................................................................... 21
Appendix A.1 Units and Abbreviations .................................................................. 22
Appendix A.2 Accreditation Information/Certifications ............................................ 30
Appendix “S” Field Work Safety Plan .......................................................................... 32
GP043AS-022762-PP-770 Page 3 of 46

List of Tables
Table 1-1 Summary of Test Program and Proposed Schedule .......................................... 5
Table 1-2 Reporting Units and Emission Limits .............................................................. 6
Table 1-3 Summary of Part 60/75 RA Requirements ...................................................... 6
Table 1-4 Test Personnel and Responsibilities ............................................................... 7
Table 2-1 CEMS Information ....................................................................................... 8
Table 2-2 Sampling Locations ..................................................................................... 9
Table 4-1 Example Parameter Emissions Results - Unit Name ....................................... 19
Table 4-2 Example <Parameter> (Units) RATA Results - Unit Name .............................. 20
List of Figures
Figure 3-1 EPA Methods 3A, 7E, and 10 Sampling Train ................................................ 13
Figure 3-2 EPA Methods 201A (PM10) and 202 Sampling Train ...................................... 15
Figure 4-1 Typical Report Format .............................................................................. 18
GP043AS-022762-PP-770 Page 4 of 46

1.0 Introduction
1.1 Summary of Test Program
PacifiCorp contracted Montrose Air Quality Services, LLC (Montrose) to perform a
Compliance and RATA emissions test program at PacifiCorp’s Currant Creek Utah Plant
located in Mona, UT. The tests are conducted to evaluate compliance with the applicable
emission limits in UDEQ Approval Order DAQE-AN125240009-15.
The specific objectives are to:
• Perform annual Particulate Matter (PM) compliance testing on the exhaust
stacks of Units CTG1A and CTG1B in accordance with the requirements of
UDEQ Approval Order DAQE-AN125240009-15
• Perform annual Relative Accuracy Test Audits (RATAs) on the Continuous
Emission Monitoring Systems (CEMS) installed on Units CTG1A and CTG1B in
accordance with the requirements of 40 CFR Parts 60 and 75 (as applicable)
• Conduct the test program with a focus on safety
Montrose will provide the test personnel and the necessary equipment to measure emissions
as outlined in this test plan. Facility personnel will provide the process and production data
to be included in the final report. A summary of the test program and proposed schedule is
presented in Table 1-1.

Table 1-1
Summary of Test Program and Proposed Schedule
Proposed
Test Date
Unit ID/
Source Name Activity/Parameters Test Methods
No. of
Runs
Duration
(Minutes)
1/30/2024 CTG1A O₂, NOx, CO EPA M3A, 7E, 10 9-12 21
PM10, CPM EPA M201A, 202 3 120
1/31/2024 CTG1B O₂, NOx, CO EPA M3A, 7E, 10 9-12 21
PM10, CPM EPA M201A, 202 3 120

To simplify this test plan, a list of Units and Abbreviations is included in Appendix A.
Throughout this test plan, chemical nomenclature, acronyms, and reporting units are not
defined. Please refer to the list for specific details.
GP043AS-022762-PP-770 Page 5 of 46

1.2 Applicable Regulations and Emission Limits
The results from this test program are presented in units consistent with those listed in the
applicable regulations or requirements. The reporting units and emission limits are
presented in Table 1-2.
Table 1-2
Reporting Units and Emission Limits
Unit ID/
Source
Name Parameter Reporting Units Emission Limit
Emission Limit
Reference
CTG1A,
CTG1B PM/PM10 lb/hr 13.3 DAQE-AN125240009-15
CTG1A,
CTG1B PM/PM10 lb/mmBtu 0.066 DAQE-AN125240009-15
The RA requirements are presented in Table 1-3.
Table 1-3
Summary of Part 60/75 RA Requirements
Parameter/Units
Regulatory
Reference Performance Specification
Part 60
Nitrogen Oxides (NOx as NO2)
ppmvd @ 15% O2 PS-2 ≤ 20.0% of RM or ≤ 10.0% of AS
lb/hr PS-6 ≤ 20% of RM or ≤ 10% of AS
Carbon Monoxide (CO)
ppmvd @ 15% O2 PS-4A ≤ 10% of RM or ≤ 5% of AS or |d̄|+CC ≤ 5 ppmvd CO
lb/hr PS-6 ≤ 20% of RM or ≤ 10% of AS
Part 75
Oxygen (O2)
% volume dry App. B Sect. 2.3.1.2 Annual: ≤ 7.5% of RM or ± 0.7% CO2
Nitrogen Oxides (NOx as NO2)
lb/mmBtu App. B Sect. 2.3.1.2 Annual: ≤ 7.5% of RM or ± 0.015 lb/MMBtu(1)
(1) Alternate is for low emitter (average RM emission rates are ≤ 0.200 lb/MMBtu)

GP043AS-022762-PP-770 Page 6 of 46
1.3 Key Personnel
A list of project participants is included below:
Facility Information
Source Location: PacifiCorp
Currant Creek Generating Station
W 300 N
Mona, Utah 84645
Project Contact: Tom Wiscomb
Role: Environmental Advisor
Company: PacifiCorp
Telephone: [phone]
Email: [e-mail]
Erik Ricardo
Sr Environmental Analyst
PacifiCorp
[phone]
[e-mail]
Agency Information
Regulatory Agency: Utah Department of Environmental Quality, Division of Air Quality
Agency Contact: Rob Leishman
Telephone: [phone]
Email: [e-mail]
Testing Company Information
Testing Firm: Montrose Air Quality Services, LLC
Contact: Craig Kormylo
Title: District Manager
Telephone: [phone]
Email: [e-mail]
Table 1-4 details the roles and responsibilities of the test team.
Table 1-4
Test Personnel and Responsibilities
Role Primary Assignment Additional Responsibilities
Field Project Manager Operate mobile lab Facility interface, test crew coordination
Technician Execute stack platform
responsibilities Preparation, support PM
GP043AS-022762-PP-770 Page 7 of 46

2.0 Plant and Sampling Location Descriptions
2.1 Process Description, Operation, and Control
Equipment
Currant Creek Generating Station comprises two combined-cycle combustion turbines
designated CTG1A and CTG1B.
2.2 CEMS Description
The CEMS analyzers are presented in Table 2-1.
Table 2-1
CEMS Information
Location Analyzer Type Manufacturer Model No. Part 75 ID
CT1A
O2 Thermo 48iQ 111
NOx Thermo 42iQ 112
CO Thermo 48iQ –––
CT1B
O2 Thermo 48iQ 211
NOx Thermo 42iQ 212
CO Thermo 48iQ –––

GP043AS-022762-PP-770 Page 8 of 46

2.3 Flue Gas Sampling Locations
Actual stack measurements, number of traverse points, and location of traverse points will
be evaluated in the field as part of the test program. Table 2-2 presents the anticipated
stack measurements and traverse points for the sampling locations listed.
Table 2-2
Sampling Locations
Sampling
Location
Stack Inside
Diameter
(in.)
Distance from Nearest Disturbance
Number of Traverse
Points
Downstream EPA
“B” (in./dia.)
Upstream EPA
“A” (in./dia.)
CTG1A 202 864 / (4.3 Diam) 168 / (0.8 Diam) Isokinetic: 12 (3/port)
Gaseous: 12 (3/port)
CTG1B 202 864 / (4.3 Diam) 168 / (0.8 Diam) Isokinetic: 12 (3/port)
Gaseous: 12 (3/port)
Sample locations are verified in the field to conform to EPA Method 1. Acceptable cyclonic
flow conditions are confirmed prior to testing using EPA Method 1, Section 11.4.
2.4 Operating Conditions and Process Data
Emission tests are performed while the source/units and air pollution control devices are
operating at the conditions required by the permit. RATA tests are performed when the
unit(s) are operating at greater than 50% of the maximum rated/normal capacity.
Plant personnel are responsible for establishing the test conditions and collecting all
applicable unit-operating data. Data collected includes the following parameters:
• Unit Load (GMW)
• Applicable CEMS data
2.5 Plant Safety
Montrose will comply with all safety requirements at the facility. The facility Client Sponsor,
or designated point of contact, is responsible for ensuring routine compliance with plant
entry, health, and safety requirements. The Client Sponsor has the authority to impose or
waive facility restrictions. The Montrose test team leader has the authority to negotiate any
deviations from the facility restrictions with the Client Sponsor. Any deviations must be
documented.
2.5.1 Safety Responsibilities
Planning
• Montrose must complete a field review with the Client Sponsor prior to the
project date. The purpose of the review is to develop a scope of work that
identifies the conditions, equipment, methods, and physical locations that will
be utilized along with any policies or procedures that will affect our work
GP043AS-022762-PP-770 Page 9 of 46

• We must reach an agreement on the proper use of client emergency services
and ensure that proper response personnel are available, as needed
• The potential for chemical exposure and actions to be taken in case of
exposure must be communicated to Montrose. This information must include
expected concentrations of the chemicals and the equipment used to identify
the substances.
• Montrose will provide a list of equipment being brought to the site, if required
by the client
Project Day
• Montrose personnel will arrive with the appropriate training and credentials
for the activities they will be performing and the equipment that they will
operate
• Our team will meet daily to review the Project Scope, Job Hazard Assessment,
and Work Permits. The Client Sponsor and Operations Team are invited to
participate.
• Montrose will provide equipment that can interface with the client utilities
previously identified in the planning phase and only work with equipment that
our client has made ready and prepared for connection
• We will follow client direction regarding driving safety, safe work permitting,
staging of equipment, and other crafts or work in the area
• As per 40 CFR Part 60 Subpart A, Section 60.8, the facility must provide the
following provisions at each sample location:
o Sampling ports, which meet EPA minimum requirements for testing. The
caps should be removed or be hand-tight.
o Safe sampling platforms
o Safe access to the platforms and test ports, including any scaffolding or
man lifts
o Sufficient utilities to perform all necessary testing
• Montrose will use the client communication system, as directed, in case of
plant or project emergency
• Any adverse conditions, unplanned shutdowns or other deviations to the
agreed scope and project plan must be reviewed with the Client Sponsor prior
to continuing work. This will include any safe work permit and hazard
assessment updates.
Completion
• Montrose personnel will report any process concerns, incidents or near misses
to the Client Sponsor prior to leaving the site
• Montrose will clean up our work area to the same condition as it was prior to
our arrival
GP043AS-022762-PP-770 Page 10 of 46

• We will ensure that all utilities, connection points or equipment have been
returned to the pre-project condition or as stated in the safe work permit. In
addition, we will walk out the job completion with Operations and the Client
Sponsor if required by the facility.
2.5.2 Safety Program and Requirements
Montrose has a comprehensive health and safety program that satisfies State and Federal
OSHA requirements. The program includes an Illness and Injury Prevention Program, site-
specific safety meetings, and training in safety awareness and procedures. The basic
elements include:
• All regulatory required policies/procedures and training for OSHA, EPA and
FMCSA
• Medical monitoring, as necessary
• Use of Personal Protective Equipment (PPE) and chemical detection equipment
• Hazard communication
• Pre-test and daily toolbox meetings
• Continued evaluation of work and potential hazards
• Near-miss and incident reporting procedures as required by Montrose and the
Client
Montrose will provide standard PPE to employees. The PPE will include but is not limited to;
hard hats, safety shoes, glasses with side shields or goggles, hearing protection, hand
protections, and fall protection. In addition, our trailers are equipped with four gas detectors
to ensure that workspace has no unexpected equipment leaks or other ambient hazards.
The detailed Site Safety Plan for this project is attached to this test plan in Appendix “S”.
GP043AS-022762-PP-770 Page 11 of 46

3.0 Sampling and Analytical Procedures
3.1 Test Methods
The test methods for this test program have been presented in Table 1-1. Additional
information regarding specific applications or modifications to standard procedures is
presented below.
3.1.1 EPA Methods 3A, 7E and 10
Determination of Oxygen, Carbon Dioxide, Nitrogen Oxides, and Carbon
Monoxide Concentrations in Emissions from Stationary Sources
(Instrumental Analyzer Procedures)
Concentrations of O₂, CO₂, NOx, and CO are measured simultaneously using EPA Methods
3A, 7E, and 10, which are instrumental test methods. Conditioned gas is sent to a series of
analyzers to measure the gaseous emission concentrations. The performance requirements
of the method must be met to validate the data.
Pertinent information regarding the performance of the method is presented below:
o A dry extractive sampling system is used to report emissions on a dry
basis
o A paramagnetic analyzer is used to measure O₂
o A nondispersive infrared analyzer is used to measure CO₂
o A chemiluminescent analyzer is used to measure NOx
o A gas filter correlation nondispersive infrared analyzer is used to measure
CO
o NO and NO₂ are measured separately and summed to report NOx
emissions
The typical sampling system is detailed in Figure 3-1.
GP043AS-022762-PP-770 Page 12 of 46

Figure 3-1
EPA Methods 3A, 7E, and 10 Sampling Train

3.1.2 EPA Method 201A
Determination of PM10 and PM2.5 Emissions from Stationary Sources
(Constant Sampling Rate Procedure)
To measure PM10, extract a sample of gas at a predetermined constant flow rate through
an in-stack sizing device. The particle-sizing device separates particles with nominal
aerodynamic diameters of 10 micrometers. To minimize variations in the isokinetic sampling
conditions, you must establish well-defined limits. After a sample is obtained, remove
uncombined water from the particulate, then use gravimetric analysis to determine the
particulate mass for each size fraction.
3.1.3 EPA Method 202
Dry Impinger Method for Determining Condensable Particulate Emissions
from Stationary Sources
The CPM is collected in dry impingers after filterable PM has been collected on a filter
maintained as specified in either Method 5 of Appendix A-3 to 40 CFR 60, Method 17 of
Appendix A-6 to 40 CFR 60, or Method 201A of Appendix M to 40 CFR 51. The organic and
GP043AS-022762-PP-770 Page 13 of 46

aqueous fractions of the impingers and an out-of-stack CPM filter are then taken to dryness
and weighed. The total of the impinger fractions and the CPM filter represents the CPM.
Compared to the version of Method 202 that was promulgated on December 17, 1991, this
method eliminates the use of water as the collection media in impingers and includes the
addition of a condenser followed by a water dropout impinger immediately after the final in-
stack or heated filter. This method also includes the addition of one modified Greenburg
Smith impinger (backup impinger) and a CPM filter following the water dropout impinger.

CPM is collected in the water dropout impinger, the modified Greenburg Smith impinger,
and the CPM filter of the sampling train as described in this method. The impinger contents
are purged with nitrogen immediately after sample collection to remove dissolved SO₂ gases
from the impinger. The CPM filter is extracted with water and hexane. The impinger solution
is then extracted with hexane. The organic and aqueous fractions are dried and the residues
are weighed. The total of the aqueous and organic fractions represents the CPM.

The potential artifacts from SO₂ are reduced using a condenser and water dropout impinger
to separate CPM from reactive gases. No water is added to the impingers prior to the start
of sampling. To improve the collection efficiency of CPM, an additional filter (the “CPM
filter”) is placed between the second and third impingers

The typical sampling system is detailed in Figure 3-2.
GP043AS-022762-PP-770 Page 14 of 46

Figure 3-2
EPA Methods 201A (PM10) and 202 Sampling Train

3.2 Process Test Methods
The applicable regulations do not require process samples to be collected during this test
program.

GP043AS-022762-PP-770 Page 15 of 46

4.0 Quality Assurance and Reporting
4.1 QA Audits
Montrose has instituted a rigorous QA/QC program for its air quality testing. Quality
assurance audits are performed as part of the test program to ensure that the results are
calculated using the highest quality data available. This program ensures that the emissions
data we report are as accurate as possible. The procedures included in the cited reference
methods are followed during preparation, sampling, calibration, and analysis. Montrose is
responsible for preparation, calibration, and cleaning of the sampling apparatus. Montrose
will also perform the sampling, sample recovery, storage, and shipping. Approved contract
laboratories may perform some of the preparation and sample analyses, as needed.
4.2 Quality Control Procedures
Montrose calibrates and maintains equipment as required by the methods performed and
applicable regulatory guidance. Montrose follows internal procedures to prevent the use of
malfunctioning or inoperable equipment in test programs. All equipment is operated by
trained personnel. Any incidence of nonconforming work encountered during testing is
reported and addressed through the corrective action system.
4.2.1 Equipment Inspection and Maintenance
Each piece of field equipment that requires calibration is assigned a unique identification
number to allow tracking of its calibration history. All field equipment is visually inspected
prior to testing and includes pre-test calibration checks as required by the test method or
regulatory agency.
4.2.2 Audit Samples
When required by the test method and available, Montrose obtains EPA TNI SSAS audit
samples from an accredited provider for analysis along with the samples. Currently, the
SSAS program has been suspended pending the availability of a second accredited audit
sample provider. If the program is reinstated, the audit samples will be ordered. If required
as part of the test program, the audit samples are stored, shipped, and analyzed along with
the emissions samples collected during the test program. The audit sample results are
reported along with the emissions sample results.
4.3 Data Analysis and Validation
Montrose converts the raw field, laboratory, and process data to reporting units consistent
with the permit or subpart. Calculations are made using proprietary computer spreadsheets
or data acquisition systems. One run of each test method is also verified using a separate
example calculation. The example calculations are checked against the spreadsheet results
and are included in the final report. The “Standard Conditions” for this project are 29.92
inches of mercury and 68 °F.
GP043AS-022762-PP-770 Page 16 of 46

4.4 Sample Identification and Custody
The on-site Field Project Manager will assume or assign the role of sample and data
custodian until relinquishing custody. The sample custodian will follow proper custody
procedures before departing from the test site including:
• Assign the unique sample identification number to each sample
• Attach sample labels and integrity seals to all samples
• Complete COC form(s), ensuring that the sample identification numbers on
the samples match the sample identification numbers on the COC
• Pack and store samples in accordance with the test method requirements in
appropriate transport containers for protection from breakage, contamination,
or loss
• Keep samples in a secure locked area if not in the direct presence of Montrose
staff
The sample custodian will follow proper custody procedures upon arriving at the Montrose
office including:
• Remove samples and COC documents from vehicles and check into
designated secure sample holding areas
• Store samples requiring additional measures such as refrigeration or dry ice
appropriately
4.5 Quality Statement
Montrose is qualified to conduct this test program and has established a quality
management system that led to accreditation with ASTM Standard D7036-04 (Standard
Practice for Competence of Air Emission Testing Bodies). Montrose participates in annual
functional assessments for conformance with D7036-04 which are conducted by the
American Association for Laboratory Accreditation (A2LA). All testing performed by Montrose
is supervised on site by at least one Qualified Individual (QI) as defined in D7036-04
Section 8.3.2. Data quality objectives for estimating measurement uncertainty within the
documented limits in the test methods are met by using approved test protocols for each
project as defined in D7036-04 Sections 7.2.1 and 12.10. Additional quality assurance
information is included in the appendices. The content of this test plan is modeled after the
EPA Emission Measurement Center Guideline Document (GD-042).
4.6 Reporting
Montrose will prepare a final report to present the test data, calculations/equations,
descriptions, and results. Prior to release by Montrose, each report is reviewed and certified
by the project manager and their supervisor, or a peer. Source test reports will be
submitted to the facility within 25 days of the completion of the field work. The report will
GP043AS-022762-PP-770 Page 17 of 46

include a series of appendices to present copies of the intermediate calculations and
example calculations, raw field data, laboratory analysis data, process data, and equipment
calibration data.
4.6.1 Example Report Format
The report is divided into various sections describing the different aspects of the source
testing program. Figure 4-1 presents a typical Table of Contents for the final report.
Figure 4-1
Typical Report Format
Cover Page
Certification of Report
Table of Contents
Section
1.0 Introduction
2.0 Plant and Sampling Location Descriptions
3.0 Sampling and Analytical Procedures
4.0 Test Discussion and Results
5.0 Internal QA/QC Activities
Appendices
A Field Data and Calculations
B Facility CEMS and Process Data
C Laboratory Analysis Data
D Quality Assurance/Quality Control
E Regulatory Information

4.6.2 Example Presentation of Test Results
Table 4-1 presents the typical tabular format that is used to summarize the compliance
results in the final source test report. Separate tables will outline the results for each target
analyte and compare them to their respective emissions limits.

GP043AS-022762-PP-770 Page 18 of 46

Table 4-1
Example Parameter Emissions Results -
Unit Name
Parameter/Units Run 1 Run 2 Run 3 Average
Date XX XX XX XX
Time XX XX XX XX
Process Data
parameter 1, units XX XX XX XX
parameter 2, units XX XX XX XX
Sampling & Flue Gas Parameters
sample duration, minutes XX XX XX XX
O2, % volume dry XX XX XX XX
CO2, % volume dry XX XX XX XX
flue gas temperature, °F XX XX XX XX
moisture content, % volume XX XX XX XX
volumetric flow rate, dscfm XX XX XX XX
<Parameter>
ppmvd XX XX XX XX
ppmvd @ 15% O2 XX XX XX XX
lb/hr XX XX XX XX
tons/yr XX XX XX XX
lb/MMBtu XX XX XX XX

GP043AS-022762-PP-770 Page 19 of 46

Table 4-2 presents the typical tabular format that is used to summarize the RATA results in
the final source test report. Separate tables will outline the results for each CEMS
parameter/set of units and compare them to their respective RA requirements.
Table 4-2
Example <Parameter> (Units) RATA Results -
Unit Name
Run
No. Date Time RM CEMS Difference
Run used
(Y or N)
Unit Load
(units)
1 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
2 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
3 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
4 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
5 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
6 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
7 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
8 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
9 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
10 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
11 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
12 XX/XX/XXXX XXXX-XXXX XX XX XX X XX
Averages XX XX XX X XX

Applicable Standard (AS) XX units
Standard Deviation XX
Confidence Coefficient (CC) XX
Bias Adjustment Factor (BAF) XX
Unit Load XX units
RA based on mean RM value XX %
RA based on AS XX %
RA based on difference plus CC XX units
RA based on absolute difference XX units

GP043AS-022762-PP-770 Page 20 of 46

Appendix A
Supporting Information

GP043AS-022762-PP-770 Page 21 of 46

Appendix A.1
Units and Abbreviations

GP043AS-022762-PP-770 Page 22 of 46
@ X% O2 corrected to X% oxygen (corrected for dilution air)
|CC|absolute value of the confidence coefficient
|d|absolute value of the mean differences
ºC degrees Celsius
ºF degrees Fahrenheit
ºR degrees Rankine
" H2O inches of water column
13.6 specific gravity of mercury
ΔH pressure drop across orifice meter, inches H2O
ΔP velocity head of stack gas, inches H2O
θ total sampling time, minutes
µg microgram
ρa density of acetone, mg/ml
ρw density of water, 0.9982 g/ml or 0.002201 lb/ml
acfm actual cubic feet of gas per minute at stack conditions
An cross-sectional area of nozzle, ft2
As cross-sectional area of stack, square feet (ft2)
Btu British thermal unit
Bws proportion by volume of water vapor in gas stream
Ca particulate matter concentration in stack gas, gr/acf
CAvg average unadjusted gas concentration, ppmv
CDir measured concentration of calibration gas, ppmv
cf or ft3 cubic feet
cfm cubic feet per minute
CGas average gas concentration adjusted for bias, ppmv
CM average of initial and final system bias check responses from upscale calibration gas, ppmv
cm or m3 cubic meters
CMA actual concentration of the upscale calibration gas, ppmv
CO average of initial and final system bias check responses from low-level calibration gas, ppmv
Cp pitot tube coefficient
Cs particulate matter concentration in stack gas, gr/dscf
CS calibration span, % or ppmv
CS measured concentration of calibration gas, ppmv
CV manufactured certified concentration of calibration gas, ppmv
D drift assessment, % of span
dcf dry cubic feet
dcm dry cubic meters
Dn diameter of nozzle, inches
Ds diameter of stack, inches
dscf dry standard cubic feet
dscfm dry standard cubic feet per minute
dscm dry standard cubic meters
Fd F-factor, dscf/MMBtu of heat input
fpm feet per minute
fps feet per second
ft feet
ft2 square feet
g gram
gal gallons
gr grains (7000 grains per pound)
gr/dscf grains per dry standard cubic feet
hr hour
UNITS AND ABBREVIATIONS
GP043AS-022762-PP-770 Page 23 of 46
UNITS AND ABBREVIATIONS
I percent of isokinetic sampling
in inch
k kilo or thousand (metric units, multiply by 103)
K kelvin (temperature)
K3 conversion factor 0.0154 gr/mg
K4 conversion factor 0.002668 ((in. Hg)(ft3))/((ml)(°R))
kg kilogram
Kp pitot tube constant (85.49 ft/sec)
kwscfh thousand wet standard cubic feet per hour
l liters
lb/hr pounds per hour
lb/MMBtu pounds per million Btu
lpm liters per minute
m meter or milli
M thousand (English units) or mega (million, metric units)
m3 cubic meters
ma mass of residue of acetone after evaporation, mg
Md molecular weight of stack gas; dry basis, lb/lb-mole
meq milliequivalent
mg milligram
Mg megagram (106 grams)
min minute
ml or mL milliliter
mm millimeter
MM million (English units)
MMBtu/hr million Btu per hour
mn total amount of particulate matter collected, mg
mol mole
mol. wt. or MW molecular weight
Ms molecular weight of stack gas; wet basis, lb/lb-mole
MW molecular weight or megawatt
n number of data points
ng nanogram
nm nanometer
Pbar barometric pressure, inches Hg
pg picogram
Pg stack static pressure, inches H2O
Pm barometric pressure of dry gas meter, inches Hg
ppb parts per billion
ppbv parts per billion, by volume
ppbvd parts per billion by volume, dry basis
ppm parts per million
ppmv parts per million, by volume
ppmvd parts per million by volume, dry basis
ppmvw parts per million by volume, wet basis
Ps absolute stack gas pressure, inches Hg
psi pounds per square inch
psia pounds per square inch absolute
psig pounds per square inch gauge
Pstd standard absolute pressure, 29.92 inches Hg
Qa volumetric flow rate, actual conditions, acfm
Qs volumetric flow rate, standard conditions, scfm
Qstd volumetric flow rate, dry standard conditions, dscfm
R ideal gas constant 21.85 ((in. Hg) (ft3))/((°R) (lbmole))
GP043AS-022762-PP-770 Page 24 of 46
UNITS AND ABBREVIATIONS
SBfinal post-run system bias check, % of span
SBi pre-run system bias check, % of span
scf standard cubic feet
scfh standard cubic feet per hour
scfm standard cubic feet per minute
scm standard cubic meters
scmh standard cubic meters per hour
sec second
sf, sq. ft., or ft2 square feet
std standard
t metric ton (1000 kg)
T 0.975 t-value
Ta absolute average ambient temperature, ºR (+459.67 for English)
Tm absolute average dry gas meter temperature, ºR (+459.67 for English)
ton or t ton = 2000 pounds
tph or tons/hr tons per hour
tpy or tons/yr tons per year
Ts absolute average stack gas meter temperature, ºR (+459.67 for English)
Tstd absolute temperature at standard conditions
V volt
Va volume of acetone blank, ml
Vaw volume of acetone used in wash, ml
Vlc total volume H2O collected in impingers and silica gel, grams
Vm volume of gas sampled through dry gas meter, ft3
Vm(std)volume of gas measured by the dry gas meter, corrected to standard conditions, dscf
Vma stack gas volume sampled, acf
Vn volume collected at stack conditions through nozzle, acf
Vs average stack gas velocity, feet per second
Vwc(std)volume of water vapor condensed, corrected to standard conditions, scf
Vwi(std)volume of water vapor in gas sampled from impingers, scf
Vwsg(std)volume of water vapor in gas sampled from silica gel, scf
W watt
Wa weight of residue in acetone wash, mg
Wimp total weight of impingers, grams
Wsg total weight of silica gel, grams
Y dry gas meter calibration factor, dimensionless
GP043AS-022762-PP-770 Page 25 of 46
AAS atomic absorption spectroscopy
ACDP air contaminant discharge permit
ACE analyzer calibration error, percent of span
AD absolute difference
ADL above detection limit
AETB Air Emissions Testing Body
AS applicable standard (emission limit)
ASTM American Society For Testing And Materials
BACT best achievable control technology
BDL below detection limit
BHP brake horsepower
BIF boiler and industrial furnace
BLS black liquor solids
CC confidence coefficient
CD calibration drift
CE calibration error
CEM continuous emissions monitor
CEMS continuous emissions monitoring system
CERMS continuous emissions rate monitoring system
CET calibration error test
CFR Code of Federal Regulations
CGA cylinder gas audit
CHNOS elemental analysis for determination of C, H, N, O, and S content in fuels
CNCG concentrated non-condensable gas
CO catalytic oxidizer
COC chain of custody
COMS continuous opacity monitoring system
CPM condensible particulate matter
CPMS continuous parameter monitoring system
CT combustion turbine
CTM conditional test method
CTO catalytic thermal oxidizer
CVAAS cold vapor atomic absorption spectroscopy
De equivalent diameter
DE destruction efficiency
Dioxins polychlorinated dibenzo-p-dioxins (pcdd's)
DLL detection level limited
DNCG dilute non-condensable gas
ECD electron capture detector
EIT Engineer In Training
ELCD electoconductivity detector (hall detector)
EMPC estimated maximum possible concentration
EPA US Environmental Protection Agency
EPRI Electric Power Research Institute
ES emission standard (applicable limit)
ESP electrostatic precipitator
EU emission unit
FCCU fluid catalytic cracking unit
FGD flue gas desulfurization
FI flame ionization
FIA flame ionization analyzer
FID flame ionization detector
FPD flame photometric detector
FPM filterable particulate matter
FTIR Fourier-transform infrared spectroscopy
FTPB field train proof blank
FTRB field train recovery blank
Furans polychlorinated dibenzofurans (pcdf's)
GC gas chromatography
ACRONYMS
GP043AS-022762-PP-770 Page 26 of 46
ACRONYMS
GC/MS gas chromatography/mass spectroscopy
GFAAS graphite furnace atomic absorption spectroscopy
GFC gas filter correlation
GHG greenhouse gas
HAP hazardous air pollutant
HC hydrocarbons
HHV higher heating value
HPLC high performance liquid chromatography
HRGC/HRMS high-resolution gas chromatography/high-resolution mass spectroscopy
HRSG heat recovery steam generator
IC ion chromatography
ICAP inductively-coupled argon plasmography
ICPCR ion chromatography with a post-column reactor
ICP-MS inductively coupled plasma-mass spectroscopy
IR infrared radiation
ISO International Standards Organization
kW kilowatts
LFG landfill gas
LHV lower heating value
LPG liquified petroleum gas
MACT maximum achievable control technology
MDI methylene diphyenyl diisocyanate
MDL method detection limit
MNOC maximum normal operating conditions
MRL method reporting limit
MS mass spectrometry
NA not applicable or not available
NCASI National Council For Air And Steam Improvement
NCG non-condensable gases
ND not detected
NDIR non-dispersive infrared
NESHAP National Emissions Standards For Hazardous Air Pollutants
NG natural gas
NIOSH National Institute For Occupational Safety And Health
NIST National Institute Of Standards And Technology
NMC non-methane cutter
NMOC non-methane organic compounds
NMVOC non-methane volatile organic compounds
NPD nitrogen phosphorus detector
NSPS New Source Performance Standards
OSHA Occupational Safety And Health Administration
PAH polycyclic aromatic hydrocarbons
PCB polychlorinated biphenyl compounds
PCW P plywood and composite wood products
PE Professional Engineer
PFAS per- and polyfluoroalkyl substances (PFAS)
PI photoionization
PID photoionization detector
PM particulate matter
PM10 particulate matter less than 10 microns in aerodynamic diameter
PM2.5 particulate matter less than 2.5 microns in aerodynamic diameter
POM polycyclic organic matter
PS performance specification
PSD particle size distribution
PSEL plant site emission limits
PST performance specification test
PTE permanent total enclosure
PTM performance test method
GP043AS-022762-PP-770 Page 27 of 46
ACRONYMS
QA/QC quality assurance and quality control
QI Qualified Individual
QSTI Qualified Source Testing Individual
RA relative accuracy
RAA relative accuracy audit
RACT reasonably available control technology
RATA relative accuracy test audit
RCTO rotary concentrator thermal oxidizer
RICE stationary reciprocating internal combustion engine
RM reference method
RTO regenerative thermal oxidizer
SAM sulfuric acid mist
SCD sulfur chemiluminescent detector
SCR selective catalytic reduction system
SD standard deviation
Semi-VOST semivolatile organic compounds sample train
SRM standard reference material
TAP toxic air pollutant
TBD to be determined
TCA thermal conductivity analyzer
TCD thermal conductivity detector
TGNENMOC total gaseous non-ethane non-methane organic compounds
TGNMOC total gaseous non-methane organic compounds
TGOC total gaseous organic compounds
THC total hydrocarbons
TIC tentatively identified compound
TO thermal oxidizer
TO toxic organic (as in EPA Method TO-15)
TPM total particulate matter
TSP total suspended particulate matter
TTE temporary total enclosure
ULSD ultra-low sulfur diesel
UV ultraviolet radiation range
VE visible emissions
VOC volatile organic compounds
VOST volatile organic sample train
W C water column
W WTP waste water treatment plant
GP043AS-022762-PP-770 Page 28 of 46
Ag silver Se selenium
As arsenic SO2 sulfur dioxide
Ba barium
SO3 sulfur trioxide
Be beryllium
SOx sulfur oxides
C carbon TCDD tetrachlorodibenzodioxin
Cd cadmium TCDF tetrachlorodibenzofuran
CdS cadmium sulfide TGOC total gaseous organic concentration
CH2O formaldehyde THC total hydrocarbons
CH3CHO acetaldehyde Tl thallium
CH3OH methanol TRS total reduced sulfur compounds
CH4 methane Zn zinc
C2H4O ethylene oxide
C2H6 ethane
C3H4O acrolein
C3H6O propionaldehyde
C3H8 propane
C6H5OH phenol
Cl2 chlorine
ClO2 chlorine dioxide
CO carbon monoxide
Co cobalt
CO2 carbon dioxide
Cr chromium
Cu copper
EtO ethylene oxide
EtOH ethyl alcohol (ethanol)
H2 hydrogen
H2O water
H2O2 hydrogen peroxide
H2S hydrogen sulfide
H2SO4 sulfuric acid
HCl hydrogen chloride
Hg mercury
IPA isopropyl alcohol
MDI methylene diphyenyl diisocyanate
MeCl2 methylene chloride
MEK methyl ethyl ketone
MeOH methanol
Mn manganese
N2 nitrogen
NH3 ammonia
Ni nickel
NO nitric oxide
NO2 nitrogen dioxide
NOx nitrogen oxides
O2 oxygen
P phosphorus
Pb lead
PCDD polychlorinated dibenzo-p-dioxins
PCDF polychlorinated dibenzofurans
Sb antimony
CHEMICAL NOMENCLATURE
GP043AS-022762-PP-770 Page 29 of 46

Appendix A.2
Accreditation Information/Certifications

GP043AS-022762-PP-770 Page 30 of 46

Accredited Air Emission Testing Body

A2LA has accredited
MONTROSE AIR QUALITY SERVICES

In recognition of the successful completion of the joint A2LA and Stack Testing Accreditation Council (STAC)
evaluation process, this laboratory is accredited to perform testing activities in compliance with
ASTM D7036:2004 - Standard Practice for Competence of Air Emission Testing Bodies.

Presented this 4th day of February 2022.

_______________________
Vice President, Accreditation Services
For the Accreditation Council
Certificate Number 3925.01
Valid to February 29, 2024

This accreditation program is not included under the A2LA ILAC Mutual Recognition Arrangement.
A merican Association for Laboratory Accreditation
GP043AS-022762-PP-770 Page 31 of 46

Appendix “S”
Field Work Safety Plan

GP043AS-022762-PP-770 Page 32 of 46

SITE SAFETY PLAN BOOKLET

Project: _____________________
Customer: ___________________
Location: ____________________
Units: _______________________
Client Project Manager: ______________________
Revision Date: January 21, 2022
GP043AS-022762-PP-770 Page 33 of 46
Page 1 of 2

Site Safety Plan and JHA Purpose and Instructions

Purpose
Employee safety is the top priority of Montrose Environmental Group. All employees must be
trained to assess and mitigate hazards. The District Manager and Project Manager are
responsible to ensure all hazards have been properly identified and managed. All employees
have Stop Work Authority in all situations where an employee feels they or their co-worker
cannot perform a job safely or if there is a task for which they have not been adequately trained.
The Site Safety Plan (SSP) has been developed to help assist Montrose test crews with
identifying physical and health hazards and determining how the hazards will be managed.
Additionally, the SSP will help each crew manage the safety of the employees by providing
emergency procedures and information. The booklet contains a several safety forms that may
be required in the field.
Instructions
The SSP consists of the following:

communicated to all employees, signed, and posted.
Supervisor/ CPM will ensure that this Emergency Action Plan Form is completed,
CPM will maintain a roster and be responsible for accounting for all employees. The Job
to work commencing. In the event of an emergency situation/ evacuation, the Job Supervisor/
emergency and evacuation procedures, assembly/ rally points, alert systems, and signals prior
the Emergency Action Plan form and ensure that all employees are familiar with the facility
4. Emergency Action Plan - The Job Supervisor/ Client Project Manager (CPM) will complete
observed plus applicable PPE that may be required.
administrative controls that a crew can use to reduce or eliminate the hazards they have
3. Hazard Control Matrix - contains useful information on both engineering and
with the toolbox topic and signatures can be added to the SSP packet.
the hazard analysis is required daily for the duration of the test. An additional sheet of paper
modified when conditions change. A toolbox meeting with a daily topic in addition to a review of
sign on the Job Hazard Analysis form in agreement and sign in Section 10. The JHA is to be
Each team member has the option to discuss making changes or adding to the JHA and must
Section 9 will require at least three tasks, hazards and controls be identified for the project.
form for accuracy, making any corrections required and complete the remainder of the JHA.
complete the JHA form through section 8. Upon arrival at the test site, the team will review the
daily hazard review with sign off by the team. The client Project Manager is responsible to
task/site’s particular hazards and controls. The form also includes a daily toolbox topic and
2. A Job Hazard Analysis is a standardized, two-page, fillable form that is used to evaluated the
prior to the test.
1. A Pre-Mobilization Test Plan – To be completed in it’s entirety by the client project Manager
AQS-FRM-1.13R1
Extended Hours Formc.
Heat Stress Prevention Form Based on Heat Indexb.
MEWP Lift Inspection Forma.
Additional Forms, as applicable5.
GP043AS-022762-PP-770 Page 34 of 46
Page 2 of 2

Site Safety Plan and JHA Purpose and Instructions

The SSP is a living document. The Project Manager should continually update their SSPs as
new information and conditions change or if new hazards are presented.
Each completed SSP should be maintained with the Test Plan in the office for a period of 3
years. There will be an audit process developed for the Site Safety Plans.

AQS-FRM-1.13R1
GP043AS-022762-PP-770 Page 35 of 46
Page 1 of 2
PRE-MOBILIZATION TEST INFORMATION

Source Type: New Source: ____ Revisit: ____ Prj#/Date/Tech: __________________________
Coal Fired Electric Utility: ____ Ethanol Plant: ____ Chemical Mfg. of _________________________
Cement/Lime Kiln Plant: ____ Specialty Mfg. of: ___________ Other: _______________

Anticipated Effluent Composition – check all that apply and fill in expected concentration in ppm/%

CO NOX SO2 VOC other
If other, explain: _______________________________________________________

Flammable: _______ Toxic: ________ Corrosive: _______ Dust: __________
Engineering Controls to be Implemented:
______________________________________________________________________________________
__________________________________________________________________________________
Additional Safety Equipment Required:
Personal gas monitors: ____
Respiratory Protection:
Half Face____ Full Face____ HEPA Filters____ Supplied Air: _____ (Safety Dept. Approval)
Approximate Flue Gas Temperatures, (F)

below 210 210 to 450 450 to 950 above 950 other
If other, explain: _______________________________________________________
Approximate Duct Pressure, (iwg):

below -3 -3 to +3 +3 to +7 above +7 other
If other, explain: _______________________________________________________

PROJECT NAME/LOCATION: ______________________ PROJECT #: ____________________
TEST DATE: ______________________ PROJECT MANAGER: ___________________
TEST SCOPE: _________________________________________________________________
SITE CONTACT: Name: _____________________ Contact Phone: _________________________
AQS-FRM-1.17
GP043AS-022762-PP-770 Page 36 of 46
Page 2 of 2
PRE-MOBILIZATION TEST INFORMATION

Sampling Location: Stack Port ____ Duct Port ____
Approximate Sampling Platform Height, (ft)

Effluent Chemical Regulatory Limits

Gas Name Chemical
Formula
Cal OSHA PEL1
(ppm)
Cal OSHA
STEL2
(ppm)
NIOSH REL
TWA3 (ppm)
Cal OSHA
Ceiling
(ppm)
IDLH4
(ppm)
Carbon Monoxide CO 25 200 35 200 1,200
Nitric Oxide NOx 25 ND5 25 ND 100
Sulfur Dioxide SO2 2 5 2 ND 100
Hydrogen Chloride HCl 0.3 2 ND 2 50
Hydrogen Sulfide H2S 10 15 10 (10 min.)C 50 100
1: California Occupational Safety and Health Administration (OSHA) Permissible Exposure Limit (PEL) based on an 8-hour shift;
2: Cal OSHA Short-term Exposure Limit (STEL) based on a 15-minute period;
3: National Institute for Occupational Safety and Health (NIOSH) Recommended Exposure Limit (REL) Time-weighted Average (TWA) based
on an 8-hour shift;
4: Immediately Dangerous to Life or Health (IDLH);
5: Not Defined (ND);
C: Ceiling Limit - Maximum allowable human exposure limit for an airborne or gaseous substance, which is not to be exceeded, even
momentarily.

Prepared by: Date:
Reviewed by: Date:

______________________________________________________________________________
______________________________________________________________________________
Additional Information:
______________________________________________________________________________
______________________________________________________________________________
Describe how equipment will be mobilized to the sampling location:
Other:_____________________________________________________________________________
Guardrails: ____ Toe plate: ____ Engineered Tie Off Points: ____ Heat Shield: ____
Elevators: ____ Ladders: ____ MEWP Lift: ____ Scaffold: ____ Equipment Hoist: ____
Access and Protection:
If other, explain: _______________________________________________________
below 6 6 to 50 50 to 100 above 100 other
AQS-FRM-1.17
GP043AS-022762-PP-770 Page 37 of 46
Job Hazard Analysis 1 of 3
1.
Client Rep
Job Preparation
Job Site Walk Through Completed Site Specific Training Complete
Safe Work Permit Received from Client
2.Facility Information/Emergency Preparedness
If non-emergency medical attention is needed, call: AXIOM #: 877-502-9466.
Plant Emergency # Certified First Aid Person:
EMS Location Evacuation Routes Rally Point
Severe Weather Shelter Location Eye Wash & Safety Shower Location
Operational: Yes No
Source Information: (list type):
Stack Gas Temp. (oF)Stack Gas Press. ("H2O)Stack Gas Components:
Stack Gas Inhalation Potential?Yes No If yes, see List of Hazard Chemicals.
3.Error Risk
Time Pressure Remote Work Location > 12 hr shift Working > 8 consecutive days
Lack of procedures Extreme temps, wind >30mph Personal illness/fatigue Vague work guidance
Monotonous Activity First day back after time off Multiple job locations Other:
4.Physical Hazards Hazard Controls
Dust Hazards Dust Mask Goggles Other:
Thermal Burn Hot Gloves Heat Shields Other Protective Clothing:
Electrical Hazards Connections Protected from Elements External GFCI Other:
XP Rating Requirement Intrinsically Safe Requirement
Inadequate Lighting Install Temporary Lighting Headlamps
Slip and Trip Housekeeping Barricade Area Other:
Hand Protection Cut Resistant Gloves Pinch Pts.General Electrical Impact Resistant
Other:
Potential Hazards for Consideration
Secondary Permits Hot Work Confined Space Excavation
Working from Heights Falling objects Fall protection Drop zone protection Platform load ratings
See also Sect. 7 Scaffold inspection Ladder inspection Barricades for equipment
Electrical Exposed wire/connector Verify equipment grounding Arc Flash
Lifting Crane lift plan Rigging inspection Tag lines used Hoists in place
Respiratory Unexpected exposure Chemical Dust (combustible)PEL provided
See also Sect. 8 Cartridges or supplied air available Gas detection equipment
5.Required PPE Hard Hats Safety Glasses Safety Toe Shoe/Boot Hearing Protection Safety Spotter
Hi-Vis Vests Harness/Lanyard*Goggles Personal Monitor Type:
Metatarsal Guards Hot Gloves Face Shield Respirator Type:
Nomex/FRC Other PPE:
Client Contact Name Date
Facility SSP Writer PM
If the heat index is expected to be above 91°, fill out the Heat Stress Prevention Form.
All hazards and mitigation steps must be documented.
If this JHA does not cover all the hazards identified,
use Section 9 to document that information.
AQS-FRM-1.18
GP043AS-022762-PP-770 Page 38 of 46
Job Hazard Analysis 2 of 3
Additional Work Place Hazards
6.Critical Procedures – check all that apply – *indicates additional form must be completed or collected from client
Heat Stress Prevention*Confined Space*Roof Work Scaffold
Cold Weather Work Hazardous Energy Control*Other:
7.Working From Heights
Fall Protection Fixed Guardrails/Toe boards Fall Prevention PPE Warning Line System
Falling Objects Protection Barricading Netting House Keeping Tethered Tools Catch Blanket or Tarp
Fall Hazard Communication Adjacent/Overhead Workers Contractor Contact Client Contact
8.Other Considerations
Environmental Hazards - Weather Forecast
Heat/Cold Lightning Rain Snow Ice Tornado Wind Speed
Steps for Mitigation:
Electrical Safety Planning
Plant Hook up:110V 220/240V 480V Generator Hard wired into panel
Electrical Classified Area: Yes No Trailer Grounded: Yes No Plug Type
Electrical Hook Up Responsibility:
List of Hazardous Chemicals Other Chemicals:
Acetone Nitric Acid Hydrogen Peroxide Compressed Gases
Hexane Sulfuric Acid Isopropyl Alcohol Flammable Gas
Toluene Hydrochloric Acid Liquid Nitrogen Non-Flammable Gas
H2S Carbon Monoxide
Steps for Mitigation:
Wildlife/Fauna in Area
Poison Ivy Poison Oak Insects:Wildlife:
Personnel w/ known allergies to bees stings or other allergens?Yes No
9.Observed Hazards and Mitigation Steps
Task Potential Hazard(s)Steps for Mitigation
● 1 1
2 2
3 3
● 1 1
2 2
3 3
● 1 1
2 2
3 3
● 1 1
2 2
3 3
Exposure Monitoring
MEWP*
AQS-FRM-1.18
GP043AS-022762-PP-770 Page 39 of 46
Job Hazard Analysis 3 of 3
10.JHA REVIEW: Crew Names & Signatures
11.Daily JHA Meeting & Review
Items to review:
● Change in conditions ● Extended work hours ● Daily Safety Topic
● New workers or contractors ● Occurrence of near misses or injuries
Printed Name Signature
2
Discussion TopicDay
Initialing demonstrates that site conditions and hazards have not changed from the original SSP. If changes did occur, make the
necessary updates to this JHA and add notes as applicable in Section 9.
Initials
9
8
7
6
3
Date Printed Name Signature Date
5
4
11
10
AQS-FRM-1.18
GP043AS-022762-PP-770 Page 40 of 46
1
2
3
4
5
6 Local Hospital/ Clinic Telephone Number:
7
8
9
10
11
12
13
14
15
16
17
MEG Job Supervisor/ CPM's Telephone Number:
Plant's #1 Contact Person's Name:
Plant's #1 Contact Person's Telephone Number:
MEG Job Safety Supervisor's Telephone Number:
Plant's Emergency Telephone Number:
Emergency Ops Radio Channel:
The Fire Extinguisher is Located:
Eye Wash and Safety Shower Location:
The First Aid Kit is Located:
Page 1 of 2
The Job Supervisor/ Client Project Manager (CPM) will ensure that all employees are familiar with the facility emergency and evacuation
procedures, assembly/ rally points, alert systems, and signals prior to work commencing. In the event of an emergency situation/
evacuation, the Job Supervisor/ CPM will maintain a roster and be responsible for accounting for all employees. The Job Supervisor/
CPM will ensure that this Emergency Action Plan Form is completed, communicated to all employees, and posted.

• You must follow the client’s emergency action plan first, and notify your Supervisor immediately.
•If incident is life threatening, CALL 911 IMMEDIATELLY
• If non-emergency medical attention is needed, call AXIOM Medical number: 877-502-9466.
EMERGENCY ACTION PLAN FORM
MEG Job Supervisor/ CPM's Name:
MEG Job Safety Supervisor (if applicable):
Evacuation Routes:
Severe Weather Shelter Location:
Plant's #2 Contact Person's Name:
Plant's #2 Contact Person's Telephone Number:
Designated Assembly Point Location:
AQS-FRM-1.11
GP043AS-022762-PP-770 Page 41 of 46
1
2
4
5
Signature:Date:Printed Name:Signature:Date:
EVACUATE:____________________________________;
OTHER:_______________________________________;
Alarm Tones:
EMERGENCY ACTION PLAN FORM AND EVACUATION ASSEMBLY MAP REVIEW: Crew Names and Signatures
Printed Name:
Draw the evacuation and assembly map here
Page 2 of 2
EMERGENCY EVACUATION AND ASSEMBLY MAP
3
Designated Shelter(s) Description:
Designated Assembly Point(s) Description:
YES or NO
Facility Name:
Facility Alarm (Circle):
FIRE:_________________________________________;
CHEMICAL/ GAS:_______________________________;
SHELTER-IN-PLACE:_____________________________;
AQS-FRM-1.11
GP043AS-022762-PP-770 Page 42 of 46

Serial Number:
Make: Rented or Owned:

• Check “Yes” if an item is adequate, operational, and safe.
• Check “No” to indicate that a repair or other corrective action is required prior to use.
• Check “N/A” to indicate “Not Applicable.”
Yes No N/A

☐ ☐ ☐
2. Hydraulic fluid level is sufficient, with the platform fully lowered ☐ ☐ ☐
3. Hydraulic system pressure (see manufacturer specs) is acceptable.
If the pressure is low, determine cause and repair in accordance with accepted procedures
as outlined in service manual.
☐ ☐ ☐
4. Tires and wheel lug nuts (for tightness) ☐ ☐ ☐
5. Hoses and cables (i.e. worn areas or chafing) ☐ ☐ ☐
6. Platform rails and safety gate (no damage present) ☐ ☐ ☐
7. Pivot pins secure ☐ ☐ ☐
8. Welds are not cracked and structural members are not bent or broken ☐ ☐ ☐
9. Warning and instructional labels are legible and secure, and load capacity is clearly marked. ☐ ☐ ☐
10. Manufacturer’s Instruction Manual is present inside the bucket ☐ ☐ ☐
11. Base controls (switches and push buttons) can be properly operated ☐ ☐ ☐
12. Platform conditions are safe (i.e. not slippery) ☐ ☐ ☐
13. Fire extinguisher is present, mounted and fully charged, located inside the bucket ☐ ☐ ☐
14. Headlights, safety strobe light and back-up alarm are functional ☐ ☐ ☐
15. Workplace is free of hazards (overhead powerlines, obstructions, level surface, high winds,
etc.) *Do not operate if winds are 20 mph, unless otherwise specified by manufacturer
recommendations.
☐ ☐ ☐

Number Item to be Inspected
Operator Name & Signature Location Date

Ground Control Name & Signature Location Date

Harness Inspections:

Printed Name Signature Date

Printed Name Signature Date

Printed Name Signature Date
Daily MEWP Lift Inspection Form
Page 1 of 1
at the beginning of each shift or following 6 to 8 hours of use.
All checks must be completed prior to each work shift, before operation of the MEWP lift. This checklist must be used
MEWP Lift Model #:
loose hoses, etc.) – if something can be easily loosened by hand then it is not sufficient.
1. All MEWP lift components are in working condition (i.e. no loose or missing parts, torn or
Items to be Inspected
AQS-FRM-1.16
GP043AS-022762-PP-770 Page 43 of 46
Page 1 of 1
001AS-SAFETY-FM-3
Extended Hours Safety Audit

Project Number: Date: Time:

When a project is expected to extend past a 14-hour work day, this form must be completed to evaluate
the condition of the crew, and the safety of the work environment.

Permission to proceed into extended work hours must come from a District Manager (DM) or Regional Vice
President (RVP). Technical RVPs can authorize moving forward, if they are in the field or if they are
managing the project.

1. Hold test crew meeting Test crew initials:

The test leader should look for signs of the following in their crews:
• Irritability
• Lack of motivation
• Headaches
• Giddiness
• Fatigue
• Depression
• Reduced alertness, lack of concentration and
memory

The test leader should assess the environmental and hazardous concerns:
• Temperature and weather
• Lighting
• Working from Heights
• Hoisting
• PPE (i.e. respirators, etc.)
• Pollutant concentration in ambient air (SO2,
H2S, ect.)

N

• Reason for extended hours
• Reason for delay
▪ Production limitations
• Impending Weather

3. Contact the client
The PM, DM or RVP must discuss with client any identified safety concerns, the client’s needs and
mutually agree on how to proceed. Discussion should also include the appropriate rest period
needed before the next day’s work shift can begin. The DM and/or a RVP must be informed on the
final decision.
Final Outcome:

Approver:

During this time, they can come to an agreement on how to proceed. Items to discuss include:
extended work period. If the DM is the acting PM on the job site, they must contact the RVP.
The PM must contact either the DM or RVP to discuss the safety issues that may arise due to the
Notify DM or RVP2.
GP043AS-022762-PP-770 Page 44 of 46
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001AS-SAFETY-FM-5

Heat Stress Prevention Form

This form is to be used when the Expected Heat Index is above 91° F, and is to be kept with project
documentation.

Project Manager (PM): Expected High Temp:
Date(s): Expected Heat Index:

1. Review the signs of Heat Exhaustion and Heat Stroke

2. If Heat Index is above 91° F:
• Provide cold water and/or sports drinks to all field staff (avoid caffeinated drinks and energy
drinks which can increase core temperature).
o Bring no less than one gallon of water per employee
• If employee(s) are dehydrated, on blood pressure medication or not acclimated to heat,
ensure they are aware of the heightened risk for heat illness
• Provide cool head bands/vests/etc.
• Have ice available to employees
• Implement work shift rotations and breaks, particularly for employees working in direct
sunlight.
• Provide as much shade at the jobsite as possible, including tarps, tents or other acceptable
temporary structures.
• PM should interview each field staff periodically to evaluate for signs of heat illness

3. If Heat Index is above 103° F:
• Employees must stop for drinks and breaks every hour (about 4 cups/hour)
• Employees are not permitted to work alone for more than one hour at a time without a
break offering shade and drinks
• Employees should wear cool bands and vests if working outside more than one hour at a
time
• PM should interview each field staff every 2 hours to evaluate for signs of heat illness

GP043AS-022762-PP-770 Page 45 of 46

This is the Last Page of This Document
If you have any questions, please contact one of the following
individuals by email or phone.

Name: Craig Kormylo
Title: District Manager
Region: Great Plains
Email: [e-mail]
Phone: [phone]

GP043AS-022762-PP-770 Page 46 of 46