Laserfiche WebLink
W.Q.# NW1-2318159 <br /> Tanknology Inc. Polis 100-29-A <br /> 8501 N.MoPac Expressway,Suite 400 Austin,TX 78759 (8.�-0o l0 y <br /> Rev:D <br /> JOB CLEARANCE FORM& Remised:8104r2008 <br /> SITE SAFETY CHECKLIST—OVF <br /> Site Namef#: Street Address: W.O. <br /> Arrival Time: Departure Time: Travel Time: others on site: Date <br /> 1�11D 11 , no k -5- <br /> Scope of Work and Tasks Performed(.lSA's must be avallablg for all tasks): <br /> Repairstq E9 uipment r Parts Provided: <br /> l Ii[F� <br /> Follow-up actions required;equipment isolated;comments: <br /> 1 S Ga L <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark—Nnot a ficabfe <br /> Safety Vest Safety Glasses Gloves I_I Hearing Protection <br /> Steel Toe Boots ! Splash Gaggles Hard Hat I.._1 Other <br /> _ ✓ PRE-TEST PROCEDURES Check each Item completed or mark ^ lfaot a ilcable <br /> 1. X Discuss safety procedures with site personnel. Nearest hospital: 1✓ U <br /> 2. Prior to fuel deliveries the UST system must be placed back into working order. <br /> 3. C 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 /> s, �1L Implement LockoutfTagout per API 1646(when accessing product piping during tasks) <br /> Alt applicable equipment disabled during test(s). X Secure the circuit breaker(s)with lockout devices and tags- <br /> Secure nozzles with'Out of Service'bags and nylon ties, _K Verify LOTO is complete by trying to oper pumps. <br /> Close ball valves or check valves on product piping. L..1 Disconnect electrical"bayonet"co r from the STP(s). <br /> SIGN IN Lead Technician Name L ad Technician ignatme <br /> General Safety Checks: <br /> Ail site personnel have been informed. YAC <br /> Fuel delivery has been informed. fy to Representarive Name je Aati„e Signature <br /> Is a fuel delivery due today? V (� <br /> LOTO procedures have been discussed and agreed. J4 r 1 6 t- <br /> Work areas barricaded to protect workers,staff&public. l have discussed'ob clearance form with technician. <br /> ✓ POST-TEST.PROCEDURES Check each item completed or mark -- if rpot applicabfe <br /> 1. Remove all"LockoutlTagoul"devices. <br /> 2. Run all pumps and verify there are no leaks: 1 1 Impact Valve Test Ports under dispensers <br /> Leak Detector Threads on STP's 1 1 Functional Elements&Relief Screws <br /> 3. ❑ Install lead wire seat on all test plugs&leak detectors that were serviced. <br /> Count LD threads: Ll_ L2_ L3 L4_ L5_ L6 <br /> 4. \� Check following components operational: ❑ ATG probes,sensors,&caps <br /> ❑ Ball floats,dry breaks&caps (.7 Cathodic protection operational <br /> i] Containment sumps are dry C7 Dispensers&POS operational <br /> ❑ Dispenser panels are replaced ❑ Drop tubes,fill adapters&caps <br /> ❑ Leak detectors&verl tubes C] Manhole covers and sump lids <br /> El Monitoring system is operational Cl Shear valves are open <br /> ❑ Siphon lines and manifold valves !-1 Siphon lines and manifold valves <br /> ❑ STP fittings and bayonet connectors i 1 Vents(not capped,plugged or isolated) <br /> 5. Remove barricades. <br /> SIGN OUT&Operator Verification of Work(OVF) Lead TeOmaan Name L erhnia Sign»tore <br /> General Safety Checks: Com, <br /> Work area has been left tidy&safe. <br /> Site staff are aware of work status including any remaining isolation. Site RepreseoWwe Name i prase 1 ti�re nature <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe.situations reported. <br /> Sile Represenlattve CommerW <br /> COMPANY CONFIDENTIAL 0 Tanknology Inc.,201 t.Act nights Reserved. <br /> Printed copies of this dxutnent are uncontrolled.The current version is available in the Tanknol_ On-Linc Document CummI 5tcm <br />