DAQ-2024-007398

DAQC-329-24
Site ID 13031 (B4)

MEMORANDUM

TO: STACK TEST FILE – PACIFICORP – Lake Side Power Plant

THROUGH: Harold Burge, Major Source Compliance Section Manager

FROM: Paul Morris, Environmental Scientist

DATE: April 10, 2024

Subject: Source: CTG11, CTG12, CTG21, and CTG22
Contact: Veronica Reyes – 801-796-1916
Location: 1825 North Pioneer Lane, Lindon, Utah County, UT
Test Contractor: Montrose Air Quality Services
FRS ID #: UT0000004904900241
Permit/AO#: Title V operating permit 4900241002 dated July 16, 2021
Subject: Review of Stack Test Protocol Dated April 10, 2024

On April 10, 2024, Utah Division of Air Quality (DAQ) received a protocol for testing of the PacifiCorp
Lake Side Power Plant combustion turbines CTG11, CTG12, CTG21, and CTG22, in Vineyard, Utah.
Testing will be performed on June 11-14, 2024, to determine compliance with Part 63 (40 CFR 63),
Subpart YYYY.

PROTOCOL CONDITIONS:

1. RM 3A used to determine dry molecular weight of the gas stream: OK
2. RM 320 used to determine formaldehyde emissions: OK
DEVIATIONS: No deviations were noted.

CONCLUSION: The protocol appears to be acceptable.

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

6 , 3
Source Test Plan for 2024
40 CFR Part 63, Subpart YYYY Compliance Testing
CTG11, CTG12, CTG21 and CTG22
PacifiCorp
Lake Side Power Plant
Lindon, Utah
Prepared For:
PacifiCorp – Lake Side Power Plant
1825 N. Pioneer Lane
Lindon, Utah
Prepared By:
Montrose Air Quality Services, LLC
990 West 43rd Avenue
Denver, Colorado 80211
For Submission To:
Utah Division of Air Quality
195 North, 1950 West
Salt Lake City, Utah 84116
Document Number: GP043AS-039920-PP-829
Proposed Test Dates: June 11
th through 14th, 2024

PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

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:4/4/2024
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:4/4/2024
Name:Tim Wojtach Title: Account Manager

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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol
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 Flue Gas Sampling Locations ........................................................................ 8
2.3 Operating Conditions and Process Data .......................................................... 8
2.5 Plant Safety ............................................................................................... 9
2.5.1 Safety Responsibilities ........................................................................ 9
2.5.2 Safety Program and Requirements ...................................................... 10
3.0 Sampling and Analytical Procedures ..................................................................... 11
3.1 Test Methods ............................................................................................ 11
3.1.1 EPA Method 3A ................................................................................. 11
3.1.2 EPA Method 320/ASTM D6348 ............................................................ 12
4.0 Quality Assurance and Reporting ......................................................................... 14
4.1 QA Audits ................................................................................................. 14
4.2 Quality Control Procedures .......................................................................... 14
4.2.1 Equipment Inspection and Maintenance ............................................... 14
4.2.2 Audit Samples .................................................................................. 14
4.3 Data Analysis and Validation ....................................................................... 14
4.4 Sample Identification and Custody ............................................................... 15
4.5 Quality Statement ..................................................................................... 15
4.6 Reporting................................................................................................. 15
4.6.1 Example Report Format ..................................................................... 15
4.6.2 Example Presentation of Test Results ................................................... 16
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PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol
List of Appendices
A Supporting Information ..................................................................................... 18
A.1 Units and Abbreviations ............................................................................. 19
A.2 Accreditation Information/Certifications ....................................................... 2
“S” Field Work Safety Plan......................................................................................
List of Tables
1-1 Summary of Test Program and Proposed Schedule ................................................ 5
1-2 Reporting Units and Emission Limits .................................................................... 6
1-3 Test Personnel and Responsibilities ...................................................................... 7
2-1 Sampling Locations ........................................................................................... 8
4-1 Example Emissions Results ................................................................................ 17
List of Figures
3-1 EPA Method 3A and FTIR Sampling Train ............................................................. 12
4-1 Typical Report Format ...................................................................................... 16
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

1.0 Introduction
1.1 Summary of Test Program
PacifiCorp contracted Montrose Air Quality Services, LLC (Montrose) to perform emission
test programs on Combustion Turbine CTG11, CTG12, CTG21, and CTG22 exhaust stacks
located at PacifiCorp’s Lake Side Power Plant located in Lindon, Utah.
The purpose of the test programs will be to determine the concentrations of formaldehyde
(CH2O). Testing will be performed in order to demonstrate compliance with the published
standard of 91 parts per billion by volume dry basis (ppbv db) @ 15% O2 from the Code of
Federal Regulations, Title 40, Part 63 (40 CFR 63), Subpart YYYY – National Emission
Standard for Hazardous Air Pollutants for Stationary Combustion Turbines.
The specific objectives are to:
Determine the concentrations of CH2O on CTG11, CTG12, CTG21, and CTG22
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 Dates Unit ID
Activity/
Parameters
Test
Methods No. of Runs
Duration
(Minutes)
6/11/2024 CTG12 O2 EPA 3A 3 60 CH2O, H2O EPA 320
6/12/2024 CTG11 O2 EPA 3A 3 60CH2O, H2O EPA 320
6/13/2024 CTG22 O2 EPA 3A 3 60CH2O, H2O EPA 320
6/14/2024 CTG21 O2 EPA 3A 3 60CH2O, H2O EPA 320
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.

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PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

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
Parameter Reporting Units Emission Limit Emission Limit Reference
CH2O ppbvd @ 15% O2 91 ppbv db @ 15% O2 40 CFR 63, Subpart YYYY
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

1.3 Key Personnel
A list of project participants is included below:

Facility Information
Source Location: PacifiCorp
Lake Side Power Plant
1825 N. Pioneer Lane
Lindon, Utah 84024
Project Contact: Tom Wiscomb Veronica Reyes
Role: Environmental Advisor Environmental Analyst
Telephone: [phone]
Email: [e-mail] [e-mail]

Agency Information
Regulatory Agency: Utah Division of Air Quality
Agency Contact: Paul Morris
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 1-3 details the roles and responsibilities of the test team.
Table 1-3
Test Personnel and Responsibilities
Role Primary Assignment Additional Responsibilities
Account/Client Project
Manager Coordinate Project Post-test follow up
Client/Field Project
Manager Operate mobile lab Facility interface, test crew coordination
Field Technician Execute stack platform
responsibilities Preparation, support PM
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PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

2.0 Plant and Sampling Location Descriptions
2.1 Process Description, Operation, and Control
Equipment
The Lake Side Power Plant comprises four combined-cycle combustion turbines designated
CTG11, CTG12, CTG21 and CTG22. In accordance with 40 CFR 63, Subpart YYYY,
formaldehyde emissions from the gas turbine generator exhaust stacks are the subject of
this test protocol.
2.2 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 2-1 presents the anticipated
stack measurements and traverse points for the sampling locations listed.
Table 2-1
Sampling Locations
Sampling
Location
Stack Inside
Diameter
(in.)
Distance from Nearest Disturbance
Anticipated Number
of Traverse Points
Downstream EPA
“B” (in./dia.)
Upstream EPA
“A” (in./dia.)
CTG11 216 ~576/~2.7 ~120/~0.6 Gaseous: 3
CTG12 216 ~576/~2.7 ~120/~0.6 Gaseous: 3
CTG21 216 ~576/~2.7 ~120/~0.6 Gaseous: 3
CTG22 216 ~576/~2.7 ~120/~0.6 Gaseous: 3
2.3 Operating Conditions and Process Data
Emission tests are performed while the source/units and air pollution control devices are
operating within 10 percent of 100 percent load, per 40 CFR Part 63, Subpart YYYY,
§63.6120.c and Table 3.
Plant personnel are responsible for establishing the test conditions and collecting all
applicable unit-operating data. Data collected includes the following parameters:
Unit load, MW
Natural gas flow rate, scfh
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

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
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
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

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
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”.
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

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 Method 3A – Determination of Oxygen Concentrations in
Emissions from Stationary Sources (Instrumental Analyzer
Procedure)
EPA Method 3A is an instrumental test method used to measure the concentration of O2 in
stack gas. The effluent gas is continuously or intermittently sampled and conveyed to an
analyzer that measures the concentration of O2. The performance requirements of the
method must be met to validate data.
Pertinent information regarding the performance of the method is presented below:
o An extractive sampling system will be used to determine concentrations
o A paramagnetic analyzer may be used to measure O2 on a dry volume
basis
o A zirconium oxide analyzer may be used to measure O2 on a wet volume
basis
o Minimum Required Sample Duration: 60 minutes
A typical sampling system is presented in Figure 3-1.

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PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

Figure 3-1
EPA Method 3A and FTIR Sampling Train
HEATED
SAMPLE
LINE
DAS
O2 AND/OR CO2
ANALYZER
Exhaust
SIGNAL
Sample / Calibration Gas
DATA
OUTPUT
SAMPLE
CONDITIONING
SYSTEM WITH
PUMP
CALIBRATION
GAS LINE
"SAMPLE” AND “BY-PASS"
ROTAMETERS WITH FLOW
CONTROL VALVES
THREE WAY
VALVE
BY-PASS
“BIAS” ROTAMETER
WITH FLOW CONTROL
VALVE
STACK
GAS
STACK
WALL
HEATED
SAMPLE
LINE
HEATED
FILTER
“ANALYZER”
ROTAMETERS WITH
FLOW CONTROL
VALVES
EPA Protocol
Calibration Gases
MASS FLOW CONTROLLER /
CALIBRATION GAS MANIFOLD
SAMPLE PROBE
SIGNAL
FTIR Sample / Calibration Gas
Exhaust
Heated pump and filter

3.1.2 EPA Method 320/ASTM D6348 – Measurement of Vapor Phase
Organic and Inorganic Emissions by Extractive FTIR
Spectroscopy
Procedures found in EPA Method 320/ASTM D6348 will be used to measure specific analyte
concentrations for which EPA reference spectra have been developed or prepared. Extractive
emission measurements are performed using FTIR spectroscopy. The FTIR analyzer is
composed of a spectrometer and detector, a high optical throughput sampling cell, analysis
software, and a quantitative spectral library. The analyzer collects high resolution spectra in
the mid infrared spectral region (400 to 4,000 cm-1), which are analyzed using the
quantitative spectral library. This provides an accurate, highly sensitive measurement of
gases and vapors.
Pertinent information regarding the performance of the method is presented below:
o The specific analyte concentrations include H2O and formaldehyde
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

o Continuous static sampling is performed at a flow rate of approximately 6 liters
per minute
o A dynamic matrix spike is performed using a formaldehyde and nitrous oxide
(tracer) calibration gas
o Formaldehyde sampling will be performed utilizing an MKS model 2030 FTIR
analyzer equipped with MAX Starboost Techology in order to achieve the low-
level detection limits (~10-15 ppbvd) required to provide the confidence in the
low-level measurements for this program
o Minimum Required Sample Duration: 60 minutes

A typical sampling system is presented in Figure 3-1.

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PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

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.
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PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

4.4 Sample Identification and Custody
No samples are anticipated to be collected for this test program.
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 or appropriate regulatory agency (upon customer approval) within
60 days of the completion of the field work. The report will 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.
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PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

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.
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

Table 4-1
Example Emissions Results
Parameter/Units Run 1 Run 2 Run 3 Average
Date XX XX XX XX
Time XX XX XX XX
Process Data
Unit Load, MW XX XX XX XX
Natural Gas Flow Rate, scfh XX XX XX XX
Sampling & Flue Gas Parameters
O2, % volume dry XX XX XX XX
Formaldehyde
ppbvd@15%O2 XX XX XX XX

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Appendix A
Supporting Information

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Appendix A.1
Units and Abbreviations

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Appendix A.2
Accreditation Information/Certifications

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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 27th day of February 2024.
_______________________
Vice President, Accreditation Services
For the Accreditation Council
Certificate Number 3925.01
Valid to February 28, 2026
This accreditation program is not included under the A2LA ILAC Mutual Recognition Arrangement.
American Association for Laborator y Accreditation
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2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol

Appendix “S”
Field Work Safety Plan

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SITE SAFETY PLAN BOOKLET

Project: _____________________
Customer: ___________________
Location: ____________________
Units: _______________________
Client Project Manager: ______________________
Revision Date:January 21, 2022
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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
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
AQS-FRM-1.13R1
Extended Hours Formc.
Heat Stress Prevention Form Based on Heat Indexb.
MEWP Lift Inspection Forma.
Additional Forms, as applicable5.
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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
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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-039920-PP-829 Page 33 of 43
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-039920-PP-829 Page 34 of 43
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-039920-PP-829 Page 35 of 43
Job Hazard Analysis 2 of 3
Additional Work Place Hazards
6.Critical Procedures *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-039920-PP-829 Page 36 of 43
Job Hazard Analysis 3 of 3
10.JHA REVIEW: Crew Names & Signatures
11.Daily JHA Meeting & Review
Items to review:
Change in conditions
New workers or contractors
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-039920-PP-829 Page 37 of 43
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.
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-039920-PP-829 Page 38 of 43
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-039920-PP-829 Page 39 of 43

Serial Number:
Make: Rented or Owned:

Check if an item is adequate, operational, and safe.

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
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.

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
atthe 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-039920-PP-829 Page 40 of 43
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.)
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 needs and
mutually agree on how to proceed. Discussion should also include the appropriate rest period
needed 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. Itemsto 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-039920-PP-829 Page 41 of 43
Page 1 of 1

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-039920-PP-829 Page 42 of 43
PacifiCorp – Lake Side Power Plant
2024 40 CFR Part 63, Subpart YYYY Compliance Test, Source Test Protocol
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/VP Technical
Region: Great Plains Region
Email: [e-mail]
Phone: [phone]
Name: Timothy Wojtach
Title: Account Manager
Region: Great Plains Region, Denver Office
Email: [e-mail]
Phone: [phone] ext. 14304
GP043AS-039920-PP-829 Page 43 of 43