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Received on 10/29/2019 <br /> SJC EHD - CR <br /> Tanknology Inc. <br /> 11000 N. Mai 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)#. Sheet Address: City,Slate,and Zipcotle: W.O.# <br /> LODI UNIFIED SO LODI UNIFIED 820 S.CIUR Avenue I Lodi,CA 95240 AST-6703819 <br /> Arrival Time IDepartureTime: Travel Time Others on site: Dale: <br /> 10:00:00 AM COT 12:55:00 PM COT I I I Jun 18,2019 <br /> Scope of Vk,rk and Tasks Performed!(JSA's must be available for al tasks): <br /> AST SPON Formal&Annual Inspection. <br /> Repaws to Equipment or Parts 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 0 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. 0 Discuss safely procedures with site personnel.Nearest hospital: <br /> 2. ❑ Priorlofiel deliveriesthe USTsysiem mudbeplaced backintoworking order. <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 /> 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 /> ❑ Vkxk areas barricaded to protect workers,staff&public. Site Representative Name Site Representative Signature <br /> ❑ la a Mel delivery due today? Ed Bonham - -', <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 ali pumps mtl verify thereare no leaks: <br /> ❑Impact Valve Test Ports under dispensers ❑Leak Detector Threats on STP's ❑Functional Elements&Fisher Screws <br /> 2. 0 Cmfm location was returned 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 /> 0 Work area has been left tidy&safe Sandra Lawson <br /> ❑ Site staff are aware of work status including any remaining isolation <br /> Site Represmlalfve Name Site Representative Signature <br /> 0 Changes to equipment are documented and communicated <br /> ❑ All incidents,near incidents,and unsafe situations reported Ed Benham .. ... <br /> Site Represmlalfve Comments: <br />