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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/#: Street Address: City,State,and Zipcode: W.O.# <br /> JOES TRAVEL PLA 15600 S HARLAN 15600 S HARLAN RD LATHROP,CA 95330 AST-6704669 <br /> Arrival Time: Departure Time: Travel Time: Others on site: Date: <br /> 12:31:00 PM PDT 12:14:00 PM PDT Apr 24,2020 <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): <br /> Formal AST Inspection <br /> Repairs 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 Safety 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 safety procedures with site personnel.Nearest hospital: <br /> 2. ❑ Prior to fuel deliveries the UST system must be placed back into working 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 IN Lead Technician Name Lead Technician Signature <br /> General Safety Checks: <br /> 0 All site personnel have been informed. Philip Thiel G&W <br /> ❑ Fuel delivery has been informed. <br /> ❑ Work areas barricaded to protect workers,staff&public. Site Representative Name Site Representative Signature <br /> ❑ Is a fuel delivery due today? <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 and verify there are no leaks: <br /> ❑ Impact Valve Test Ports under dispensers ❑Leak Detector Threads on STP's ❑ Functional Elements&Relief Screws <br /> 2. ❑ Confirm location was returned to pre-arrival state <br /> 3. ❑ Remove barricades <br /> SIGN OUT&Operator Verification of Work(OVF) Lead Technician Name Lead Technician Signature <br /> General Safety Checks: <br /> ❑ Work area has been left tidy&safe Philip Thiel <br /> ❑ Site staff are aware of work status including any remaining isolation <br /> Site Representative Name Site Representative Signature <br /> ❑ Changes to equipment are documented and communicated <br /> ❑ All incidents,near incidents,and unsafe situations reported <br /> Site Representative Comments: <br />