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Tanknology Inc. 11000 N.MoPac Espress%cay,Suite 500 Austin,TX 78759 (800)964-OUIU Policy 100-29-A JOB CLEARANCE FORM & Reye D Revised: 1/21/2014 SITE SAFETY CHECKLIST— OVF Site Name/#: Street Address: W.O.# I-) Arrival Time Departure Time: Travel Time: z Others on site: Date Scope of Work and Tasks Performed(JSA's must be available for all tasks): Repairs to Equipment or Parts Provided: ,JUN 05 2018 Follow-up actions required:equipment isolated,comments: ENUIi`�ONNIENTAL PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark—J nota licable Safety Vest Safety Glasses _ Gloves Hearing Protection Steel Toe Boots Splash Goggles Hard Hat Other ✓ PRE-TEST PROCEDURES (Check each item completed or mark if not applicable) 1. Discuss safety procedures with site personnel. Nearest hospital: 2. Prior to fuel deliveries the UST system must be placed back into working order. 3. I 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/Tagout per API 1646(when accessing product piping during tasks) C All applicable equipment disabled during testis). 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"connector from the STP(s). SIGN IN Lead Technician Name Lead Technician Signature General Safety Checks: 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 job clearance form with technician. ✓ 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: L ATG probes, sensors, &caps u 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 D Shear valves are open ❑ Siphon lines and manifold valves ❑ Siphon lines and manifold valves 1 STP fittings and bayonet connectors ❑ Vents(not capped, plugged or isolated) 5. Remove barricades. SIGN OUT&Operator Verification of Work(OVF) Lead Technician Name Lead 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 COMPANY CONFIDENTIAL C)"Lanknoloay Inc.,2011.All Rights Reserved. Printed co pica of this document are uncontrolled. -1 he current version is a\aikihle in the TanknoloL% On-Linc Document Control Scstem.