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Tanknology Inc. <br />8501 N. MoPac Expressway, Suite 400 Austin, TX 78759 (800) 964-0010 Policy 100-29-A <br />-+rr Rev: D <br />JOB CLEARANCE FORM & Revised: 8/04/2008 <br />SITE SAFETY CHECKLIST — OVF <br />Site Name/#: <br />Street Address: <br />W O. #a'30 le 7 <br />z <br />10 -65s - S fay <br />a <br />MC 1 <br />t <br />e <br />Arrival Tim. <br />eparture Time: <br />Travel Time: <br />thers on site: <br />ate <br />�f`50 <br />r <br />( ! <br />Scope oof Work sk aGd (JS:A s m t be available for all tasks): <br />1 lJ <br />Repairs to Equipment or Parts Pro td : <br />Follow-up actions required; equipment isolated; comments: <br />PPE - PERSONAL PPQTECTIVE EQUIPMENT REQUIRE Check items used or mark —if not a licable <br />Safety Vest <br />Z Safety Glasses <br />Gloves <br />❑ Hearing Protection <br />Steel Toe Boots <br />❑ Splash Goggles <br />❑ Hard Hat <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. El Prior to fuel deliveries the UST system must be placed back into working order. <br />3. ecure entire work area with barricades (tones, flags, and caution tape, pennant flags, or other perimeter guard). <br />4. fire extinguishers and "No Smoking" signs in the work area. <br />��Place <br />5. �Im .Went Lockout/Tagout per API 1646 (when accessing pr uct piping during tasks) <br />evices and tags. <br />pplicable equipment disabled during test(s).cure the circuit breaker(s) with lone7t.r <br />Secure nozzles with "Out of Service" bags and nylon ties. YJ Verify LOTO is complete by trying ta pumps. <br />Close ball valves or check valves on product piping. ❑ isconne electrical "bayonet" conrom the STP(s). <br />9el _ <br />Ga <br />ead echn ian N <br />_ <br />Lea echnician Signature <br />General Safety Checks: <br />have been informed. <br />All site personnel <br />ite Representative Nam <br />6 <br />ite Repies ativ na e <br />Fuel delivery has been informed. <br />Is a fuel delivery due today? <br />S <br />LOTO procedures have been discussed and agreed. <br />t! <br />Work areas barricaded to protect workers, staff & public. <br />I have discus Alob clearance <br />form h <br />✓ POST-TEST PROCEDURES Check each item completed or mark — if nota icable <br />J <br />1. �J emove all "Lockout/Tagout" devices. <br />Run �mpact Valve Test Ports dispensers <br />2. all pumps and verify there are no leaks: under <br />❑ Leak Detector Threads on STP's ❑ 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 L4L5 L6 <br />4. -,e' Check following components operational: ATG probes, sensors, & caps <br />floats, dry breaks & caps ElCathodic protection operational <br />call <br />ontainment sumps are dryDispensers & POS operational <br />IQ Dispenser panels are replaced ❑ Drop tubes, fill adapters & caps <br />❑ keak detectors & vent tubes anhole covers and sump lids <br />X�Monitoring system is operational Shear valves are open <br />❑ Siphon lines and manifold valves ❑ Siphon lines and manifold valy <br />❑ STP fittings and bayonet connectors ElVents (not capped, plugged isol ed) <br />5. Remove barricades. <br />�,_ V_W;�;_ <br />Lead ethnicn me Lea Technician Signature <br />General Safety Checks: <br />Work area has been left tidy & safe. <br />Site Representative Nam S nt ve ignat e <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 />I ( 'V. <br />Representative comments: <br />Site' <br />COMPANY CONFIDENTIAL © Tanknology Inc., 2011. All Rights Reserved. <br />rinted copies of this document are uncontrolled. The current version is available in the Tanknolo On -Line Document Control S stem. <br />