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Tanknology Inc. i 8501 N.MoPac Expressway,Suite 400 Austin,TX 78759 (800)964-0010 Policy 100-29-A JOB CLEARANCE FORM & Rev:D SITE SAFETY CHECKLIST - OVF Revised:8/04/2008 Site Name/#: Street Address: W.O.# Arrival Time: Departure Time: Travel Time: Date rZILIEi� /E NFC1=&1=[) Scope of Work and Tasks Performed(JSA's must be available for all tasks): JUL 0 201 Repairs to Equipment or Paris Provided: ENVIRONMENTAL HEALTH Follow-up actions required;equipment isolated;comments: PERMIT/�crs FWARONANIEWIAL i IIEc, PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check Items used or mark—if not app licable) ❑ Safety Vest ❑ Safety Glasses ❑ Gloves ❑ Hearing Protection ❑'' Steel Toe Boots _ ❑ Splash Goggles I ❑ Hard Hat 1 ❑ Other ✓ PRE-TEST PROCEDURES (Check each Item completed or mark — if not applicable) 1. D Discuss safety procedures with site personnel. Nearest hospital: 2. ❑ Prior to fuel deliveries the UST system must be placed back into working order. 3. ❑ Secure entire work area with barricades(cones,flags, and caution tape, pennant flags, or other perimeter guard). 4. ❑ Place fire extinguishers and"No Smoking"signs in the work area. 5. ❑ Implement Lockout/Tagogt per API 1646 (when accessing product piping during tasks) ❑ All applicable equipment disabled during test(s). ❑ Secure the circuit breaker(s)with lockout devices and tags. ❑ Secure nozzles with"Out of Service"bags and nylon ties. ❑ Verify LOTO is complete by trying to operate pumps. ❑ Close ball valves or check valves on product piping. ❑ Disconnect electrical"bayonet"co hector from the STP(s). SIGN IN lead Technician Name Lead Technician Signature General Safety Checks: i All site personnel have been informed. Fuel delivery has been informed. Site Representative Name Site Representative Signature Is a fuel delivery due today? LOTO procedures have been discussed and agreed. Work areas barricaded to protect workers,staff&public. I have discussed'ob Clea ance form with techni ian. POST-TEST PROCEDURES (Check each item completed or mark ~ if not applicable) 1. ❑ Remove all "Lockout/Tagout"devices. 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers ❑ Leak Detector Threads on STP's ❑ Functional Elements&Relief Screws 3. ❑ Install lead wire seal on all test plugs&leak detectors that were serviced. Count LD threads: L1 L2 L3 L4 L5 L6 4. ❑ Check following components operational: ❑ ATG probes,sensors,&caps ❑ Ball floats,dry breaks&caps ❑ Cathodic protection operational ❑ Containment sumps are dry ❑ Dispensers&POS operational ❑ Dispenser panels are replaced ❑ Drop tubes,fill adapters&caps ❑ Leak detectors&vent tubes ❑ Manhole covers and sump lids ❑ Monitoring system is operational ❑ Shear valves are open ❑ Siphon lines and manifold valves ❑ Siphon lines and manifold valves_ ❑ STP fittings and bayonet connectors ❑ Vents(not capped, plugged 'r isolated) 5. _Remove barricades. ___ __ SIGN OUT&Operator Verification of Work(OVF)_ Lead Technician Name \ Lbad Technician Signature General Safety Checks: Work area has been left tidy&safe. Site staff are aware of work status including any remaining isolation. Site Representative Name Site Representative Signature Changes to equipment are documented and communicated. All incidents,near incidents,and unsafe situations reported. Site Representative Comments: r COMPANY CONFIDENTIAL ©Tanknology Inc.,2011.All Rights Reserved. rinted copies of this document are uncontrolled. The current version is available in the Tanknology On-Line Document Control S stem.