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W.O.# NW1-2323217 <br />Tanknology Inc. <br />i 1 OOO N. MuPac Expressway, Suite 500 Austin, TX 78759 (1100)9"0010 <br />JOB CLEARANCE FORM & <br />SITE SAFETY CHECKLIST — OVF <br />RECEIVEC <br />MAY 2 6 2015 <br />Policy 10024-A � VIRONMENTAI <br />Rev: D 1 r_ r rr- <br />y <br />Reviscd:ll242014 '1�D90T�AC�IT <br />ite Name/#: <br />Street Address: <br />W.O. <br />3r 77 <br />' I <br />3a 7 <br />6V�d <br />, <br />oZ <br />Arrival Time:parture <br />De T <br />Mars on sit <br />ate <br />Scope of Work and Tasks Performed (JSA s must be evadable for 'all tasks): t� / <br />1S5EL. <br />Repairs to Equipment or Parts Provided: <br />Follow-up actions required: equipment iso a : comments: <br />. <br />PPE • PERSONAL PROTEC77VE EQUIPMENT REQUIRED Check items used or m,A -• if nota licable <br />Safety Vest.: Safety Glasses <br />I <br />Gloves <br />Hearin? Protection <br />Steel Toe Boots l- Splash Goggles <br />Hard Hat <br />J Other <br />PRE-TEST PROCEDURES fCheceach Item cgn letedorme,* ^- If notapplicable) <br />1. Discuss safety procedures with site personnel. Nearest hospital: <br />2. Prior to fuel deliveries the UST system must be placed back into working order. <br />3. Secure entire work area with barricades (cones, flags, and caution tape, pennant flags, or other perimeter guard). <br />4. Place fire extinguishers and "No Smoking" signs in the work area. <br />5. jW implement Lockoutrfagout per API 1646 (when accessing product piping during tasks) <br />�1 All applicable equipment disabled during test(s). �'Secure the circuit breaker(s) with lockout devices and tags. <br />Secure nozzles with `Out of Service' bags and nylon t es. LcS Verify LOTO is complete by trying to operate pumps. <br />Close ball valves or check valves on product piping. Disconnect electrical"bayonet" connector from the STP(s). <br />UaG lech,,WiartNa— <br />Le en Signature <br />General Safety Checks: <br />have been informed. <br />�bC LCfsY <br />All site personnel <br />Fuel delivery has been informed. <br />neeprasamat,re14anx <br />:te a .sentaNve Sfgnawa <br />Is a fuel delivery due today? <br />LOTO rocedures have been discussed and agreed. <br />; t <br />Work areas barricaded to protect workers, staff & public. <br />- i have " "oks clearance <br />dctt <br />✓ POS7 -TEST PROCED (Check each item completed or mark ^' ft nota pucable) <br />1. Remove all 'LockoutrfagouP devices. <br />2. 4:iZ Run all pumps and verify there are no leaks: impact Valve Test Ports under dispensers <br />E Leak Detector Threads on STP's Functional Elements & Relief Screws <br />3. 0 Install lead wire seal on all test plugs & leak detectors that were serviced. <br />Count LD threads: L1 L2 L3 L4 L5 L6 <br />. _ _ _ <br />4. Check following components operational: y �T13 probes, sensors, & caps <br />Ball floats, dry breaks & caps C7 Cathodic protection operational <br />Containment sumps are dry Dispensers & POS operational <br />Dispenser panels are replaced Drop tubes, fill adapters & caps <br />Leak detectors & vent tubes Manhole covers and sump lids <br />Monitoring system is operational'kP Shear valves are open <br />4�? Siphon lines and manifold valves Siphon linesand manifold valves <br />(� STP fittings and bayonet connectors Vents (not capped, plugged or isolated) <br />5. Lam. Remove barricades. <br />Lea' Techni6un N-.,.. <br />Led -eehniei 8ignshn:j <br />General Safety Checks: <br />Work area has been left tidy & safe. <br />_5-r6t1,6 (ft l [ "oC <br />Site staff are aware of work status including any remaining Isolation. <br />ae Hapres la ve Name <br />rte ep uru <br />Changes to equipment are documented and communicated. <br />All incidents, near incidents, and unsafe situations reported. <br />Site epreaentahveamments. <br />COMPANY CONFIDENTIAL O'ranknology Inc., 2011. All Rights Reserved, <br />ni. copies ofthis document aro uncontrolled. The cwmt version is available in the'ranknolog y On -Lina Uoc;umcnt Cunirol Svatan <br />