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A KNOLOG <br />T1C. koG.!O. 1..a, <br />MANDATORY Safety Tag & Lock -Out Pre-test <br />and Quality Assurance Post-test Procedure <br />� Customer. <br />Site: <br />9S»5 <br />Service�: <br />Address: <br />city/st: <br />ZI P: <br />!/ ✓ ' C /t �L E' 1294 n/ Z� <br />PRE-TEST PROCEDURE: <br />The following items must be signed for prior to starting tank and / or <br />i line testing at site: <br />1) The station manager understands that PRIOR to FUEL DROPS the Unit Manager <br />must stop testing and place the complete station back into working order. <br />tion manage, u. ide, sta, d'S thaL Ll le Pumps, and eleet,,e-al supply <br />must stay disabled throughout the test—. <br />3) All associated power breakers have been turned off for testing. <br />4) Magnetic signs have been placed on power breaker boxes. <br />5) "Out of Service" bags are on dispenser nozzles. <br />6) Padlocks are on dispenser nozzles. <br />,7) Check e-is-elosed- <br />8) Bayonet connectoi is discenneeted ftem pump. <br />9) All safety procedures have been discussed with all station personnel. The,Station <br />Manager and Tanknology Unit Manager have each confirmed that the Tag & Lockout <br />procedures are in effect. <br />The Station Mgr. agrees that the above items were explained and <br />completed prior to the start of Tank and/or Line Testing. <br />Station Manager N��ame:,c / Sta. Mgr.Si ature: _ DATE: <br />POST-TEST PROCEDURE: <br />To insure that your station is fully operational prior to our test -unit <br />departing from your location, PLEASE WITNESS the following items: <br />1) Each dispenser operates, and all "out -of -service bags & pad -locks were removed. <br />2) There are NO LEAKS in the sub -pump area, even when the pumps are running. <br />3) All debris, safety -cones, & magnetic signs have been removed from the work area. i <br />4) All tanks and dispensers were restored to their original state. <br />The Station Mgr. agrees that the above Items were witnessed & completed <br />following the completion of Tank and/or Line Testing. i <br />Station Manager Name: <br />Sta. Mgr.Signature: <br />DATE: <br />A-c_`t:r-9,r #�-6r�-A£i-I <br />Unit Manager Name: <br />Unit i4gr. ignature: I Date: c� <br />/ <br />/ CertificabE4 <br />�� FOpµgflpt <br />Lndatl0. <br />