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Tanknology Inc. <br /> 11000 N. MoPac Expressway,Suite 500 Austin,TX 78759(800) 964-0010 policy 100-29-B <br /> INSPECTOR ONLY Rev:A <br /> SAFETY CHECKLIST - OVF <br /> Site Name)#. SloaM Add..: City,Slate,and Zipcode: W.O.# <br /> ADVANCE GEO MV TERESI TRUCK 90012 Victor Read Lodi,CA 05240 AST6703711 <br /> Arrival Time: DepartureTie: Travel Time Others on site: Dale: <br /> 10:54:00 AM POT 11:49:0 AM POT I May 6,M19 <br /> Scope of VWM and Tasks Performed!(JSA's must be available for al tusks): <br /> AST SP001 Formal hspectim. <br /> Repairs to Equipment or Paris Provided! <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED(Check items Used or mark-if not applicable) <br /> 0 Safety Vest N Safely Glasses 0 Gloves ❑ Hearing Protection <br /> 0 Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other <br /> PRE-TEST PROCEDURES (Check each item completed or mark- if not applicable) <br /> 1. N Discuss safely procedures with site personnel.Nearest hospital: <br /> 2. ❑ Priorlofiel deliveriesthe USTsysiem musibeplaced backintoworking order, <br /> 3. ❑ Secure entire work area with barricades(cones,flags, and cautiontape,pennantflags,or other perimeter guard), <br /> 4. ❑ Place fire extinguishers and"No Smoking"signs in the work area. <br /> SIGN N Lead Technician Name Lead Technician Signature <br /> General Safety Checks: ,y <br /> 0 All site personnel have been informed, Sandra Lawson - <br /> ❑ Fuel delivery has been infomed. <br /> ❑ Mork areas barricaded to protect workers,staff&public. Site Representative Name Site Representative Signature <br /> ❑ Is a Mel delivery due today? Anthony Teresi --' -- � <br /> I have discussed job clearance form with technician. <br /> POST-TEST PROCEDURES (Check each item completed or mark- if not applicable) <br /> 1. ❑ Run all pumps mtl verily there are no leaks: <br /> ❑Impact Valve Test Ports under dispensers ❑Leak Detector Threads on STP's ❑Functional Elements&Refer Screws <br /> 2. N Cmfrm location was shored to pre-arrival slate <br /> 3. ❑ Removebarricades <br /> SIGN OUT&Operator Verification of Work(OVF) Lead Technician Name Lead Technician Signature <br /> General Safety Checks: <br /> N Work area has been left tidy&safe Sandra Lawson .,. ,�.-- <br /> ❑ Site staff are aware of work status including any remaining isolation <br /> Site Representative Name Site Representative Signature <br /> N Changes to equipment are documented and communicated <br /> ❑ All incidents,near incidents,and unsafe situations reported Anthony Teresi ' <br /> Site Represmlalive Commmis: <br />