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STARS SITE NO. LEASEHOLDER                    PRIMARY CONTACT DETAILS              EMERGENCY CONTACT DETAILS                                                                                                                   LOCATION DETAILS                                                                                                                                      TEMPORARY SITE                                                                              PERMANENT SITE                                                       POTENTIAL DANGERS TO WORKERS ON SITE                                EMERGENCY RESOURCES ON SITE                                                         SITE ACCESSIBILITY                                                                   Please answer ONLY if site is GREATER THAN 40 MINUTES FROM 24 HR EMERGENCY FACILITY
                                                                                                                                  site?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Is facility
                                                                                                                                                        SURFACE location:                                                                                     Nearest Town
                                                                                                                                                                                                                                                                                                                           Site number may be moved to new location                                                                 AFE               Site number may not be moved                                                                                                                                   Highest level of   Is there a   Ambulance                 accessible                                                                                  Are you able to                               How would the   Do you have a preferred Is the medical personnel on                        Do you know if there a
                                                                                                                                                                                                                                                              With 24 Hour                                                                                                                                                                                                                                              AFE                                                                                                                                                                    Landing zone If no Landing zone, alternate
    To be              Name
                                                                                                                                                                                  Nearest                                              Direction of Town    Emergency Facility                         Direction of Town
                                                                                                                                                                                                                                                                                                                                                                                                                               (Authority for                to new locaiton
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Number of      (Authority for Expenditure)   H2S on
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     H2S                       High
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Flammable   Other Hazards?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     medical training    Medical      or vehicle            -in all weather-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                available?  location to land the helicopter
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Are you able to transport    bring patient to
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               If so, what would be a
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ELC communicate      helicopter charter       site willing to take      Do you know if     fixed wing landing strip
                of Company to be                                                                                                                         In AB, SK and MB                      Driving Directions   Driving distance                                                Driving distance                               PLEASE LIST TYPE OF WORK:                                              Number of people     Expenditure)                                                                                                        Monitor    Corrosives?   Pressure                                     on site?       Treatment    capable of    AED?       by (pick one)                                                   patient to this location?   rendezvous with                                with you, when          company?          responsibility for the care  there is any jet    in the immediate area
 completed by      billed for site
                                     Primary Contact   Contact Number   Company   Name     Contact Number   Company      Name          Contact Number   Please Provide LSD      Geographical
                                                                                                                                                                                               From Town to Site        (minutes)
                                                                                                                                                                                                                                           from Site
                                                                                                                                                                                                                                                                                        (minutes)
                                                                                                                                                                                                                                                                                                           from Site
                                                                                                                                                                                                                                                                                                                           (i.e. seismic, drilling, workover, completion,
                                                                                                                                                                                                                                                                                                                                                                            Start Date         End Date
                                                                                                                                                                                                                                                                                                                                                                                                           working on site           or             Name of Facility, Compressor Station
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           people working                or                site?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   on site?      Y or N      Lines?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Liquids?
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      i.e. Standard      Centre?       patient     Y or N                                                                                                      ground
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              common meeting point
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           enroute to              Y or N         and transport of the patient fuel in the area?      STARS can use for
                                                                                                                                                                                Town to Site                                           (N, NW, SE, etc.)     (**if different from                      (N, NW, SE, etc.)                                                                                                                                                                       on site          Project Cost Code         Y or N                                          Y or N   Provide details                                                                             (36m x 36m)             (LSD, GPS,                                                                  (half way point)?
    STARS           registration
                                                                                                                                                        In BC, Please Provide                                                                              'Nearest Geographical
                                                                                                                                                                                                                                                                                                                                  abandonment, construction, etc.)                                                           Project Cost Code                  or Battery
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Number (for Billing)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Y or N                    Y or N                                 First Aid, EMR,      (MTC)      transport?              2 wheel drive
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Y or N          hwy intersection, etc.)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Y or N               ambulance?                                  common meeting If Y, please provide name/ by a private helicopter?           Y or N          medical evacuation?
                                                                                                                                                                                                                                                                                                                                          Cost is $6 per day                                                                 Number (for Billing)           Cost is $150 per year                                                                                                                                    EMT, OFA, etc.       Y or N        Y or N              4 wheel drive?                                                                                      Y or N                                       point?        contact information               Y or N                                          Y or N
                                                                                                                                                           GPS and/or PNG                                                                                           Town')
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Other? (details)

				
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posted:10/11/2013
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