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,FEB-19-2016 11:30 INTERSTATE 01L p.06 <br /> Tanknology Inc. <br /> 11000 N.Mol?x Fx,ircsswa,,111ill I'll Austin TX 78159 (W)9,64-0010 Policy I 00-29-A <br /> 41i"Jo <br /> - Dv <br /> JOB CLEARANCE FORM & Rev' <br /> - 1/24/2014 <br /> SITE SAFETY CHECKLIST OVF <br /> Site Name/#: W.O.# <br /> YX-,�j <br /> Arrival Time: Departure Time: Travel Time: t em on site, ate <br /> Scope of WorkandPerformed(J must be available for <br /> all tasks): <br /> RECEIVED <br /> Repairs to Equipment or Parts Provided: <br /> Pollow-up actions-required;equipment isolated;comments- EFR 19 216 <br /> P -PERS FUVIRO-MENTAL <br /> PE L PROTECTIVE EQUIPMENT REQUIRED(Check items used or mar*-it not&PPR L14A F.A I TrAPDA R-M P NIT <br /> Safety Vast Safety Glass-a$ Gloves ❑ Hearing Protection <br /> Steel Too BQQtti; 17_Splatih Goggles Hard Hat ❑ Other <br /> ✓ PRE-TES T PROCEDURES (Check each item COM04ted or mark if not Mp#cable) <br /> Discuss safety procedures with site personnel. Nearest hospital: <br /> 2. Prior to fuel deliveries the UST system must be placed back into working order. <br /> 3. Secure entire work area with barricades(cones,flags, and caution tape, pennant flags, or other perimeter guard), <br /> 4, 1 Place fire extinguishers and"No Smoking"signs in the work area. <br /> 5. F1 Implement Locko'ut/Tagout per API 1646(when accessing product piping during tasks) <br /> 0 All applicable equipment disabled during test(s), E Secure the circuit breaker(s)with lockout devices and tags. <br /> Secure nozzles with'Cut of Service'bags and nylon ties. 5 Verify LOTO is complete by trying t6'bperate pumps. <br /> ❑ Close ball valves or chock valves on product piping. Fj- Discgne5�electrical"bayonet'connector from the STP(s)i. <br /> Leall TeChrl NarrAs LL-ad I ecriniclan bivaium <br /> General Safety Checks <br /> All site personnel have been informed- <br /> Fuel delivery has been informed. -Sft-r9pmwnM%m Name <br /> is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. <br /> Work areas barricaded to protect workers,staff&public. <br /> I have discussed job clearance lb-wiff tki"k <br /> ✓ POST-TEST PROCEDURES(check each item completed or mark � ffnatppW�Ycabla) <br /> 1. D Remove all"Lockoutfragout"devices. <br /> 2. 1-J Run all pumps and verity there are no leaks: Impact Valve Test Ports under dispensers <br /> I Leak Detector Threads on STP's ❑ Functional Elements&Relief Screws <br /> 3. -:-1 Install lead wire seal on all test plugs&leak detectors that were serviced. <br /> Count LD threads: Ll — L2— L3 L4 L5 L6 <br /> 4. Q Check following components operational, ❑ ATG probes,sensors, &caps <br /> El Ball floats, dry breaks&caps ❑ Cathodic protection operational <br /> ,j Containment sumps are dry C1 Dispensers&POS operational <br /> Dispenser panels are replaced D Drop tubes,fill adapters&caps <br /> i Leak detectors&vent tubes ❑ Manhole covers and sump lids <br /> ❑ Monitoring system is operational F-7 Shear valves are open <br /> Siphon lines and manifold valves D Siphon lines and manifold valves <br /> STP fittings and bayonet connectors 0 Vents(not capped, plugged or isolated) <br /> 5. IJ Remove barricades. <br /> &OPR!2�,- "d Lead Ted imiCiiirr Nam@ Lead Technician Signature <br /> General Safety Checks: <br /> Work area has been left tidy&safe. <br /> Site stuff are aware of work status including any remaining isolation. Site Represents"Name saq R#Rreson S'gn317 Z 1 <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported, <br /> 4- <br /> Silt.Represe-ntativq Conirnents: <br /> COMPANY CONFIDENTIAL t�Tanknulugy Inc.,2011.All Rights RescrvW. <br /> 1printod copies of this document arc uncontrolled. Tho current version is avaiii3ble in thcl-anknoloSy on-Line Vocument Control System <br />