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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)#. SlreM Add..: City,Shale,and Tipcode: W.O.# <br /> NORTHWEST PIPE TRACY MFG PLANT 101M W.Urine Read Tracy,CA 953T AST67OM23 <br /> Arrival Time: OepadureTme: Travel Time Others on she: Oahe: <br /> 11:20:00 AM PST 1 1:00:00 PM PST Mar 8,2010 <br /> Scope of VWrk and Tasks Performed!(JSA's mush be available for al eaks): <br /> 10 year Formal AST inspection. <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-ff not applicable) <br /> 0 Safety Vest 0 Safely Glasses 0 Gloves ❑ Hearing Protection <br /> 0 Steel Toe Boots ❑ Splash Goggles 0 Hard Hat ❑ Other <br /> PRE-TEST PROCEDURES (Check each item completed or mark- if not applicable) <br /> 1. 0 Discuss safety procedures with site personnel.Nearest hospital: <br /> 2. ❑ Priorhofuel deliveriesthe USTsysem musbeplaced backintoworking order, <br /> 3. ❑ Secure entire work area AM 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: <br /> 0 All site personnel have been informed, Sandra Lawson <br /> ❑ Fuel delivery has been informed. <br /> ❑ Vf k areas barricaded to protectworkers,staff&public. Site Representative Name Site Representative Signature <br /> ❑ is a Mel delivery due today? Denisse Ugnon fir:'^" <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 antl verily there are no leaks: <br /> ❑Impact Valve Test Ports under dispensers ❑Leak Detector Threads on STDs ❑Functional Elements&Refef Screws <br /> 2. 0 Confirm location was shored to pre-arrival date <br /> 3. ❑ Removebanicades <br /> SIGN OUT&Operator Verification of Work(OVF) Lead Technician Name Lead Technician Signature <br /> General Safety Checks: <br /> 0 Work area has been left tidy&safe Sandra Lawson <br /> 0 Site staff are aware of work status inducting any remaining isolation <br /> ❑ Changes to equipment are documented and communicated Site Representative Name Site Representative Signature <br /> ❑ All incidents,near incidents,and unsafe situations reported Denisse Ugnon <br /> Site Representative Comments: <br />