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W.O.# NW1-2318135 <br />Tanknology Inc. <br />8501 N. Mopac Expressway, Suite 400 Austin, TX 78759 (800) 964-0010 Policy 100.29-A <br />JOB CLEARANCE FORM & Revised: 8/04/2M8 <br />SITE SAFETY CHECKLIST - OVF <br />Its Na <br />Street Address: <br />ArriveTime: <br />Departure Time: <br />Travel Time: <br />Others n site: <br />Date <br />Scope of Work and Tasks Performed (J A's must be available for all tasks): <br />Repairs to Equipment or arts P ded: <br />V <br />Follow-up actiolng required; equipment isolated; comment <br />PPE - PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark — if not applicable) <br />/1"96fety Vest <br />%" Safety Glasses Gloves <br />Hearing Protection <br />Steel Toe Boots <br />Splash Goggles Hard Hat <br />Other _ <br />✓ PRE-TEST PROCEDURES (Check each item completed or mark if not applicable) <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. Implement LockouUTagout per API 1646 (when accessing product piping during tasks) <br />7 All applicable equipment disabled during testis). Secure the circuit breaker(s) with lockout device and tags. <br />1 Secure nozzles with "Out of Service' bags and nylon ties. Verify LOTO is complete by trying to operate p ps. <br />Close ball valves or check valves on product piping. C Disconnect a ctrical-bayonel" connector from the STP(s). <br />S40N IN <br />Lead Technician Name <br />'� ^ <br />Le•echo c an signature <br />General Safety Checks: <br />All site personnel have been informed. <br />' e resentati Neme <br />i posture <br />Fuel delivery has been informed. <br />Is a fuel delivery due today? <br />r <br />LOTO procedures have been discussed and agreed. <br />C <br />Work areas barricaded to protect workers, staff & public. <br />I hav dis ssed 'ob clearanceyform <br />with technician. <br />✓ POST-TEST PROCEDURES (Check each item completed or mark — if not applicable) <br />1. Remove all "LockoutlTagout" devices. <br />2. _, Run all pumps and verify there are no leaks: �' Impact Valve Test Ports under dispensers <br />J Leak Detector Threads on STP's L' Functional Elements & Relief Screws <br />3. Install lead wire seal on all test plugs & leak detectors that were serviced. <br />Count LD threads: L1 _ L2 _ L3 _ L4 _ L5 _ L6 _ <br />4. Check following components operational: l ATG probes, sensors, & caps <br />it Ball floats, dry breaks & caps I Cathodic protection operational <br />U Containment sumps are dry 7 Dispensers & POS operational <br />U Dispenser panels are replaced I Drop tubes, fill adapters & caps <br />U Leak detectors & vent tubes 1 Manhole covers and sump lids <br />0 Monitoring system is operational _ Shear valves are open <br />r Siphon lines and manifold valves Siphon lines and manifold valves <br />STP fittings and bayonet connectors Vents (riot capped, plugged or isolated) <br />5. _ Remove barricades. II <br />SIGN OUT 8 Operator Verification of Work OVF <br />Lead Technician qame <br />)'�- '•S' <br />Lead achn.-an Signalure <br />General Safety Checks: <br />Work area has been left tidy & safe. <br />Site staff are aware of work status including any remaining isolation. <br />i <br />to epr emsN.M.I• <br />ap a n sous gnature <br />Changes to equipment are documented and communicated. <br />All incidents, near incidents, and unsafe situations reported. <br />its Represenialive ommenta: <br />COMPANYCONFIAENTIAL 0 Tanknalugy Inc . 201 1. All Rights Reserved. <br />Printed copies of this dcwumem are unwntrollcd. The cement version is available in the Tatknolo On -Line Document Control S stein. <br />OVF <br />