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Work Order: 2251443 <br />Tanknologyy Inc. <br />8501 N. MaPac T:xp rs5way, Sukc 400 Austie,'rX 78759 <br />Ptax,¢- i 800) 964-00 L0 Local: ( x"].(512)451-6334 <br />SITE SAFETY CHECKLIST & <br />OPERATOR VERIFICATION FORM <br />Policy 100.29-A <br />Rev: B <br />Revised: 11.02'2006 <br />Page I of 2 <br />Site Name' <br />T Discuss safely procedures with site personnel. <br />Address. <br />2. <br />W.O. p- <br />2. <br />stem to be placed back into working order. <br />3. <br />Site E: <br />CkfylSTlLp'J <br />ution tape or pennant flags. <br />Date: <br />4, <br />1 Place fire extinguishers and -No Smoking' <br />3-7 <br />Scope of VMrkr <br />5.& <br />All applicable pumps, dispensers. and <br />a <br />rical breakers must be disabled during the <br />Parts 6 Materials Provided: <br />(s). <br />AIHvol Time: <br />6."Tum <br />Deparlure Time <br />Travel Time: <br />o)�:,zk <br />out devices and tags. <br />/,f "7 <br />7 -'Place <br />1. <br />T Discuss safely procedures with site personnel. <br />Post -Test Signature <br />JL/ <br />1. <br />2. <br />Pnor to fuel deliveries, the complete tank <br />2. <br />stem to be placed back into working order. <br />3. <br />Secure entire work area with cones, flags. and <br />ution tape or pennant flags. <br />4, <br />1 Place fire extinguishers and -No Smoking' <br />s ns in the work area, <br />3. <br />5.& <br />All applicable pumps, dispensers. and <br />rical breakers must be disabled during the <br />(s). <br />4. <br />6."Tum <br />off and secure the circuit breaker(;) with <br />out devices and tags. <br />7 -'Place <br />`Out of Service' bags and nylon ties on <br />ling. <br />enser nozzles - <br />a -*Verify <br />Lockout/Tagout procedure is complete <br />rying to operate pumps. <br />9.&Close <br />ball valves or check valves on product <br />to. <br />2 *Remove the electrical 'bayonet" connector <br />from the STP(s). <br />• <br />'Lockoul/Tagoutapplies when accessing product piping, <br />Nearest Hospital fR - t' ✓ `' S rf �/ <br />S - <br />Remove ail "LockoutlTagout' devices. <br />Run all pumps and verify there are no leaks <br />er dispensers or in STP sumps, <br />Impact Valve Test Port <br />Leak Detector Threads <br />Functional Element & Relief Screw <br />Install a lead wire seal on all test plugs a leak <br />teetom that were serviced. Count LD threads* <br />L1 L2 _ L3 _ L4 _ L5 <br />Ensure that all tank system components are <br />red to their original state (including): <br />ATG probes. sensors, & caps <br />Ball fleets, dry breaks & caps <br />Cathodic prolection operational <br />Containment sumps are dry <br />Dispensers & POS operational <br />- Dispenser panels are replaced <br />I - Drop tubes, fill adapters & caps <br />I Leak detectors & vent tubes <br />Manhole covers and sump lids <br />Monitoring system is operational <br />Shear valves are open <br />- Siphon lines and manifold valves <br />Spill containers & drain valves <br />_ - STP fittings and bayonet connectors <br />Remove cones, signs, and caution tape, <br />Tanknology Technician Name <br />Pme-Te M Signature <br />Post -Test Signature <br />JL/ <br />1. <br />Site Representative Name <br />v 't <br />Pre Test Signature <br />Post -Test Slonature <br />Comments: <br />t — <br />CUMPA\•V CUNFIDF.NTIAL <br />© Tenknt,ipgy Inc., :006. All RigtLLS Resen'cd. <br />'infect O–Vi-x of rWs document me uncontrnllcd. Themcnfyari{al is available in the Tmknol. i m Docaalent Cr,nuol 5> slam <br />Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 <br />