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W.O.# NW1-2336576 <br />Tanknology Inc. Policy 100-29-A <br />11000 N. MoPac Expressway, Suite 500 Austin, TX 78759 (800) 964-0010 Rev: D <br />JOB CLEARANCE FORM & Revised: 1/24/2014 <br />SITE SAFETY CHECKLIST — OVF <br />Site Name/#: <br />Street Address: <br />W.O. # <br />S� ��, <br />Z J j' G�7 <br />Arrival Time: Departure Time: <br />Travel Tlme: thers n site: <br />Date <br />/ <br />Scope of Work and Tasks Prtoninq tdSrss mus[ oe avauaoie ror an rasnsr. <br />Repai s to Equipment or Pans Provided: <br />Follow-up actions required; equipment isolated; comments: <br />PPE -PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used ormark - if nota licable <br />Safety VestSafety Glasses ❑ Gloves ❑ Hearing Protection <br />Steel Toe Boots 1 7— <br />Splash Goggles ❑ Hard Hat ❑ Other <br />✓ PRE TEST PROCEDURES (check each item completed or mark — if not appficable) <br />_ Discuss safety procedures with site personnel. Nearest hospital: <br />Prior to fuel deliveries the UST system must be placed back into working order. <br />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 1mpi2ment Lockout/Tagout per API 1646 (when accessing product piping during tasks) <br />- All applicable equipment disabled during test(s). _U_ 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 operate pumps. <br />Close ball valves or check valves on product piping. ❑ Disconnect electrical "bayonet' connector from the STP(s) <br />SIGN IN Lead Technician Name Lead Technician Signature <br />General Safety Checks: <br />All site personnel have been informed. — <br />Fuel delivery has been informed. Site Representative Name Site Representaave ignature <br />Is a fuel delivery due today? <br />LOTO procedures have been discussed and agreed. <br />Work areas barricaded to protect workers, staff &public. I have discussed job clearance orm with technician <br />✓ POST-TEST PROCEDURES (Check each item completed or mark — If not applicable) <br />1. L Remove all "Lockout/Tagout" devices. <br />2. _ Run all pumps and verify there are no leaks: C Impact Valve Test Ports under dispensers <br />Leak Detector Threads on STP's 1 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. 1 Check following components operational: ATG probes, sensors, & caps <br />Ball floats, dry breaks & caps 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 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 or isolated) <br />5. Remove barricades. <br />SIGN OUT & Operator Verification of Work (OVF) Lead Technician Name Lead Te nieian Signature <br />General Safety Checks: <br />Work area has been left tidy &safe. <br />Site staff are aware of work status including any remaining isolation. I Site R sanative Name esentative igna re <br />Changes to equipment are documented and communicated. <br />All incidents, near incidents, and unsafe situations reported. <br />Site Representative Comments: <br />COMPANY CONFIDENTIAL © Tanknology Inc., 2011. All Rights Reserved. <br />rinsed copies of this document are uncontrolled. The current version is available in the Tanknology On -Line Document Control S stem. <br />Ovf <br />