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W.O.# NW1-232989'3 <br />tet/ <br />I anknology Inc. <br />11000\. MOPac Expressway, Suite 500 Austin, TX 78759 (800) 964-0010 Policy 100-29-A <br />JOB CLEARANCE FORM & Rev: D <br />Revised: 1242014 <br />SITE <br />MD111" <br />Site Nargeffi. <br />Street Address <br />W. .0 <br />/1-6 it 3`13 <br />a5,1 <br />s6i r6tv A <br />- <br />Arrival Time: <br />Departure Time <br />TraverTime <br />Others on site: <br />Date <br />B'Yb <br />112 rap <br />pa-ob-�7 <br />Scrape of Work and asks Performed (SA'a must be available otasks); <br />Repairs to Eq ant or arts Provided: ✓,4/IIA2/1AI-.A,0 -pqp LIVAL VIZ -'I,.) W " -" J / v!u<- <br />O haw lL <br />oil -uD actions required equipment isolated; comments: <br />sG Aa o -m SiL AWC1 <br />PPE- PERSONAL PROTECTIVE EQUIPMENT R QUIRED Check Hems used or mark- Hnota ltcablell <br />Safety Vest QC Safety Glasses PC Gloves <br />= Heanng Protection <br />Steel Toe Boots _ Splash Goggles _ Hard Hat <br />_ Other <br />✓ PRE-TEST PROCEDURES (Check each Hem completed or mark ^' not applicable) <br />�HH/ <br />1. Discuss safety procedures with site personnel. Nearest hospital:.Svrr6n_, T/LayS�i7�iTAL <br />2. Prior to fuel deliveries the' UST system must be placed back into working order. — 835-1S O <br />3. Secure entire work area with barricades (cones, flags, and caution tape, pennant flags, or other perimeter guard). <br />4. Place fire extinguishers and "No Smoking" signs in the work area. <br />5. — Implement Lockout/Tagout per API 1646 (when accessing product piping during tasks) <br />- All applicable equipment disabled during test(s). Secure the circuit breaker(s) with lockout devices and tags. <br />- Secure noules vith'Out of Service- bags and nylon ties. - Verify LOTO is complete by trying to operate pumps. <br />Close ball valves or check valves on product piping. _ Disconnect elecrical'bayoneP connector from the STP(s). <br />SIGN IN / <br />Lead I lammcan Name <br />Toomindan lemev. <br />General Safety Checks: <br />All site personnel have been informed./(a.GykLS <br />Fuel delivery has been informed <br />SFee Representastive Name <br />ne ep n <br />Is a fuel delivery due today? . 05 <br />LOTO procedures have been discuste"nd agreed. <br />y,y Aa ' - <br />We* areas barricaded to protect workers, staff & public. <br />I have discussed bb clearance <br />form with techemician. <br />✓ POST-TEST PROCEDURES <br />(Check each item completed or mark — H not applicable) <br />1. Remove all "LockoutfTagout" devices. <br />2. - Run all pumps and verify there are no leaks: - Impact Valve Test Ports under dispensers <br />- Leak Detector Threads on STP's _ Functional Elements & Relief Screws <br />3. - Install lead wire seal on all test plugs & leak detectors that were serviced. <br />Count LD threads: Li 1-2 L3 L4 1-5 L6 <br />_ _ _ _ _ <br />4. ChV following components operational: KATG probes, sensors. & caps <br />e' <br />\ Ball Floats, dry breaks & caps _ Cathodic protection operational <br />Containment sumps are dry [ Dispensers & POS operational <br />Dispenser panels are replaced rop tubes, fill adapters &caps <br />Leak detectors 8 vent tubes anhole covers and sump lids <br />Monitoring system is operational hear valves are open <br />iss <br />Siphon lines and manifold valves iphon lines and manifold valves <br />TP fittings and bayonet connectors ants (not capped, plugged or isolated) <br />5. Remove barricades. <br />SIGN OUT & Operator Verification of Work OVF <br />rasa Tiaremoin Fears <br />SimsL16 LA)l Ut+✓1'LS <br />said red .. lruegmatij,e <br />General Safety Checks: <br />Work area has been lett tidy 8 safe <br />ire epresemabm Nimm <br />Re~t1i Si,natara <br />Site staff are aware of work status including any remaining isolation. <br />Changes to equipment are documented and communicated. <br />All incidents. near incidents. and unsafe situations reported. <br />Site Representative Comments: <br />COMPANY CONFIDENTIAL <br />r'S <br />Lv Inc.. 2011. All Rights Reser, ed. <br />7 <br />LrGlbmurmmt Connol S,nem L. _ <br />''a lac. <br />MAR 6 6 2017 <br />ENVIRONMENTAL HEALTH <br />CEPARM ENT <br />