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A KNOLOG <br /> MANDATORY Safety Tag & Lock-Out <br /> t ATENCO HTNHOELIROEGNY NFROOR NTMANENKST J �� Loc. k-Out Pre-test <br /> re-test <br /> and Quality <br /> Assurance Post-te <br /> CustomerSite#: 5t ' r` _ - u ® <br /> Service <br /> Order#: <br /> Address-. <br /> �^ (� City/St ZI R. <br /> PRE-TEST PROCEDURE: <br /> The following items must be signed for prior to starting tank and / or <br /> line testing at site: <br /> 1) The station manager understands that PRIOR to FUEL DROPS the Unit Manager <br /> must stop testing and place the complete station back into working order. <br /> 2) The station manager understands that the pumps, dispensers and electrical supply <br /> must stay disabled throughout the test. <br /> 3) All associated po%,Arer breakers have been turned off for testing. <br /> 4) Magnetic signs have been placed on power breaker boxes. <br /> 5) "Out of Service" bags are on dispenser nozzles. <br /> 6) Padlocks are on dispenser nozzles. <br /> 7) Check valve is closed. <br /> 8) Bayonet connector is disconnected from pump. <br /> 9) All safety procedures have been discussed with all station personnel. The Station <br /> Manager and Tanknology Unit Manager have each confirmed that the Tag & Lockout <br /> procedures are in effect. <br /> The Station Mgr. agrees that the above items were explained and <br /> completed prior to the start of Tank and/or Line Testing. <br /> Station Manager Name: Sta. Mgr.Signature: DATE: <br /> POST-TEST PROCEDURE: <br /> To insure that your station is fully operational prior to our test-unit <br /> departing from your location, PLEASE WITNESS the following items: <br /> 1) Each dispenser operates, andl all ":gut-cif--service bags & pad-locks were removed. <br /> 2) There are NO LEAKS in the sub-pump area, even when the pumps are running. <br /> 3) All debris, safety-cones, & magnetic signs have been removed from the work area. <br /> 4) All tanks and dispensers were restored to their original state. <br /> The Station Mgr. agrees that the above Items were witnessed & completed <br /> following the completion of Tank and/or Line Testing. <br /> Station Manager Name: Sta. Mgr.Signature: DATE: <br /> Unit Manager Name: Unit Mgr.Signature: Date: <br /> �— Certi6Cate# <br /> IndroWm4FOiNd�l1!?I <br /> TAK-27 <br />