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A KNOLOGMANDATORY Safety Tag & Lock-Out Pre-test .°"`• ' and Quality Assurance Post-test Procedure , Customer. Site»: Service Crderz: Address: City/st: ZIP: PRE-TEST PROCEDURE: The following items must be signed for prior to starting tank and / or I line testing at site: 1) The station manager understands that PRIOR to FUEL DROPS the Unit Manager must stop testing and place the complete station back into working order. 2) The station manager understands that the pumps, dispensers and electrical supply must stay disabled throughout the test. 3) All associated power breakers have been turned off for testing. 14) Magnetic signs have been placed on power breaker boxes. 5) "Out of Service" bags are on dispenser nozzles. 6) Padlocks are on dispenser nozzles. 7) Check valve is closed. 8) Bayonet connector is disconnected from pump. 9) All safety procedures have been discussed with all station personnel. The Station Manager and Tanknology Unit Manager have each confirmed that the Tag & Lockout procedures are in effect. The Station Mgr. agrees that the above items were explained and completed prior to the start of Tank and/or Line Testing. Station Manager Name: Sta. pMggr.S�ignn_ature: DATE: POST-TEST PROCEDURE: To insure that your station is fully operational prior to our test-unit departing from your location, PLEASE WITNESS the following items: 1) Each dispenser operates, and all 'out-of-service bags & pad-locks were removed. 2) There are NO LEAKS in the sub-pump area, even when the pumps are running. 3) All debris, safety-cones, & magnetic signs have been removed from the work area. 4) All tanks and dispensers were restored to their original state. The Station Mgr. agrees that the above Items were witnessed & completed following the completion of Tank and/or Line Testing. Stadon Manager Name: Sta. Mgr.Signature: DATE: Unit Manager Name: Unit Mgr. Signature: Date: G certificatL lakaWOA FOpµgitl9l 1 FORM 23