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ANK !1sR Site Safety Checklist, Service Agreement, and Operator Verification Form <br /> Site Name: Site Address: l Work Order 9 <br /> Site#: Site CI State p: Date: <br /> CA-- 7 0 <br /> Scope of Work: 4— <br /> Arrival Time on$ite: Odve Time to Site: Mileage to Site: Departure Time From Site: <br /> �Div; <br /> TESTPROCEDURES OST•TESTPROCEDURES <br /> 1 safety procedures with site personnel- 1 Remove all'LockoutiTagout'devices <br /> IC ;2 II personnel are in protective equipment and 2 �r3Run all pumps and verity there are no leaks under dispensers or In <br /> ae work areas have proper personnel, ISTP sumps. MUST BE WITNESSED BY REPRESENTATIVE. <br /> 3 ;prod <br /> ps users,and electrical breakers of the Impact Valve Test Port <br /> to be tested must be disabled during the ast(8). Wedtor Threads <br /> Fundonal Element and Relief Screw <br /> 4Secure entire work area with barricades,mires,andlor 3 7Pnor to fuel deliveries,the complete tank system must be placed <br /> caution tape, back Into Ivo mg ober. <br /> 5 Place fire extinguishers and'No Smoking'signs in 4 Ensure all lank system components are restored to their onginal <br /> the work area. stat ' duding: <br /> 6 Tum off and secure the circuit breaker(s)of the product Monitoring system probes,sensors,and caps <br /> to be tested with lockout devices and tags. Ball Floats,dry breaks,&caps <br /> 7 ❑ Pine'Out of Service-bags on the dispenser nozzles Dispenser and POS system <br /> of the products)to be tested. Dispenser panels are replaced <br /> g ❑ Verify proper LmkouVTagoul procedure is complete D ubes,fill adapters,&caps <br /> by trying to operate pumps. eek detectors&copper vent tubes <br /> 9 Ck>vee bell valves or check valves on the product piping Manhole covers and sump lids <br /> to be tested. Shear valvas at the dispensers <br /> 10 <br /> Remove the a ecb ca "bayone connector from the STP(sJ. co0tai0ers&drain valves <br /> STP fittings and bayonet connectors <br /> 5 Remove cones,signs,and caul tape. <br /> Technician N _ Post•T <br /> By signing below,you confirm that thf I andf_. TjPibC'edurea shown above have been <br /> visually verified by you. In addition,your signature below Confirms that all pumps are operating normi <br /> Site Representative Name: Post-Test Signature: <br /> I�C G I(e, <br /> Regulatory Agent Present? Regulatory Agent Name Regulatory Agent Signature <br /> � Present for testing MWN I r)l`y� � V IM R'" <br /> ff�Norle present <br /> IF RETEST NEEDED PLE62E CHECK APPLICABLE <br /> Q Tank MONITOR Q PD © VA_ <br /> F7 Line Annual sensor Q Fill sump sensor Q Blockage Q Drop Tube <br /> Q Leak Detector Q Disp. Sump sensor Q Turbine sump Q A/L Q Torque <br /> Q Spill bucket sensor Q LR PV V <br /> ® 2005.Tank-Tek Environmental Corppration,907 Elmira Road,PMB 336,Vacaville,CA 65897 <br /> 31828 Cards Chamberdn,Temecula, CA 92581 — Ph,(951)6948059 - Fax(961)69"059 - E+neil:dretanktekesdecu.net <br /> 607 Elmira Road,PMB 336,Vacaville,CA 96687 — Ph.(707)446-6151 Fax (707)4463192 - E-mail:tank•tekQCwnet.00m <br />