Who is reponsible to close the
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
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
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)
(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?
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)?
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')