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0 <br /> • d ► Tanknology <br /> SITE SAFETY CHECKLIST, SERVICE AGREEMENT& OPERATOR VERIFICATION FORM <br /> Site Name: Address: <br /> Site#: City/ST/Zip: Date: <br /> Scope of Work: <br /> Parts& Materials Provided: <br /> Arrival Time at Site: Departure Time from Site: Total Travel Time: <br /> ✓ PRE-TEST PROCEDURES ✓ POST-TEST PROCEDURES <br /> 1. ❑ Discuss safety procedures with site personnel. 1. ❑ Remove all"Lockout/Tagout"devices. <br /> 2. ❑ Prior to fuel deliveries, the complete tank system 2. ❑ Run all pumps and verify there are no leaks under dispensers or <br /> must be placed back into working order. in STP sumps. Must be witnessed by site representative. <br /> 3. ❑ All pumps, dispensers, and electrical breakers of ❑ Impact Valve Test Port <br /> the product(s) to be tested must be disabled during ❑ Leak Detector Threads <br /> the test(s). ❑ Functional Element & Relief Screw <br /> 4. ❑ Secure entire work area with 28" cones, flags, and 3. ❑ Install a lead wire seal on all test plugs & leak detectors that <br /> caution tape. were serviced. Count LD threads: <br /> 5. ❑ Place fire extinguishers and "No Smoking"signs in L1 L2 L3 L4 L5 <br /> the work area. 4. ❑ Ensure that all tank system components are restored to their <br /> F. ❑ Turn off and secure the circuit breaker(s) of the original state (including): <br /> product to be tested with lockout devices and tags. ATG probes, sensors, & caps <br /> 7. ❑ Place "Out of Service"bags on the dispenser nozzles Ball floats, dry breaks & caps <br /> of the product(s) to be tested. Cathodic protection system is operational <br /> S. ❑ Verify proper Lockout/Tagout procedure is complete - Containment sumps are dry <br /> by trying to operate pumps. Dispensers & POS system <br /> 9. iD Close ball valves or check valves on the product Dispenser panels are replaced <br /> piping to be tested- - Drop tubes, fill adapters & caps <br /> 10, ❑ Remove the electrical"bayonet"connector from - Leak detectors & copper vent tubes <br /> the STP(s). - Manhole covers and sump lids <br /> Monitoring system is operational <br /> Shear valves at the dispensers. <br /> Siphon lines and manifold valves <br /> Spill containers & drain valves <br /> - STP fittings and bayonet connectors <br /> 5. ❑ Remove cones, flags, and caution tape. <br /> Tanknology Pre Test Signature Post-Test Signature <br /> Signature below confirms that the items listed in the POST-TEST Procedures have been visually verified by the location representative, <br /> Site Representative Name Pre-Test Signature Post-Test Signature <br /> Comments: <br /> Tanknolo,gy-NDE,International Revised 11/18/02 <br />