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W.O.# NW1-2315466 <br />Cust -reef# : PO: 0015114456 <br />Tanknology Inc. <br />8501 N. MoPac Expressway. Suite 400 Austin, TX 78759 (800) 964-0010 Policy 100-29-A <br />t JOB CLEARANCE FORM & Rev: D <br />Revised: 6/04/2008 <br />SITE SAFETY CHECKLIST — OVF <br />Site Namel#: Street Address: <br />D <br />Clam 130-7 ��( i a�s5 i�>�, Int �rhx <br />a 31f G7 <br />Arrival Time: I <br />Departure T'08: Travel Time: <br />btfiers on site: <br />Date <br />I <br />Scope of Work and Tasks Performed (J!s must be av 'fable for all tasks): <br />v s <br />Repairs to Equipment or Parts Pr ided: <br />Follow-up actions required: equipment isolated; comments: <br />PPE - PERSONAL PROTECTIVE EQUIPMENT REQUIRED heck Items used or mark — Hnot applicable) <br />Safety Vest <br />Steel Toe Boots <br />Safety Glasses <br />❑ Splash Goggles <br />, Gioves <br />❑ Hard Hat <br />❑ Hearing Protection <br />❑ Other <br />✓ PRE-TEST PROCEDURES (Check each Item completed or mark " ff 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 Lockout/Tagout per API 1646 (when accessing product piping during tasks) <br />Cl All applicable equipment disabled during test(s). -1 Secure the circuit breaker(s) with lockout devices and tags. <br />Secure nozzles with "Out of Service" bags and nylon ties. ❑ Verify LOTO is complete by trying to rate pumps. <br />Close ball valves or check valves on product piping. i J_JWconnect electoral "bayonet" con ect r from the STP(s). <br />SIGN IN <br />Lead echni an me Lea TechnidanSignature <br />r4 — ,_ <br />General Safety Checks: <br />All site personnel have been informed. <br />Site Repres ivauve ame a resentative Signature <br />Fuel delivery has been informed. <br />Is a fuel delivery due today? <br />LOTO procedures have been discussed and agreed. <br />Work areas barricaded to protect workers, staff & public. <br />have dis used job clearant3alfoilm with Ktnician. <br />✓ POST-TEST PROCEDURES (check each item completed or mark — if notappficable) <br />1. J Remove all "Lockout/Tagout" devices. <br />2. Run all pumps and verity there are no leaks: J Impact Valve Test Ports under dispensers <br />❑ Leak Detector Threads on STP's ❑ Functional Elements & Relief Screws <br />3 J In 11 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: - ATG probes, sensors, & caps <br />%,( <br />B oats, dry breaks & caps 7 Cathodic protection operational <br />ontainment 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 ❑ Shear valves are open <br />Siphon lines and manifold valves ❑ Siphon lines and manifold valves <br />❑ STP fittings and bayonet connectors ❑ Vents (not capped, plugged ors ted) <br />Remove barricades. <br />5./❑ <br />SIGN OUT & Operator Verification of Work OV <br />Lead Te k1 Nam <br />Lea Tecnnician Signature <br />General Safety Checks: <br />Work area has been left tidy & safe. <br />site Representative Name <br />r� <br />yiL aeC`(�U <br />IRepre <br />entative ,gnature <br />1Q�J <br />Site staff are aware of work status including any remaining isolation. <br />Changes to equipment are documented and communicated. <br />All incidents, near incidents, and unsafe situations reported. <br />Site Representative Comments <br />COhIPANY CONFIDENTIAL © Tanknology Inc., 2011. All Rights Reserved. <br />Printed ies or this document are uncontrolled. The current version is available in the Tanknolo On -Linc Document Control System. <br />