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Tanknology Inc. <br /> 11000 N.MOPoc l-'xpresswa),Suitc i0[] Austin,TX 7ft749 (800)964-(1010 Policy 100-29-A <br /> JOS CLEARANCE FORM & Rev: <br /> 1) <br /> SITE SAFETY CHECKLIST - IVF Revised: 1124!2014 <br /> Site Name)#- Street Address' W O # <br /> 0094 /441C 6 1 3J.3 p&rQr- ,ems <br /> Arrival Time Departure Time. Travel Time hcrs an site Date <br /> �? : O%p ' : J_,Z7 2010 <br /> Scope of Work and Tasks Performed (JSA's must be available for all tasks) <br /> �7 <br /> Repairs to Equipment or Parts l' vitled <br /> Follow-up actions required; equipment isolated, rommenls: <br /> /01 <br /> PPE- PERSONAL.PR TIVE EQUiPMEN r REQUIRED heck items used or mark — if not appficable <br /> Safety Vest Safety Glasses ves Hearing Protection <br /> feel Toe Boots Splash Goggles Hard Hat Other <br /> ✓ <br /> PRE-TEST PROCEDURES (Check each Item completed or mark if not applicable) <br /> 1. SOOKriscuss 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, nags, and caution tape, pennant flags, or other perimeter guard) <br /> 4. Place fire extinguishers and "No Smoking" signs in the work area. <br /> 5. Implement LockoutlTagout per API 1646 (when accessing product piping during tasks) <br /> All applicable equipment disabled during test(s)- Secure the circuit breaker(s)with lockout devices and tags <br /> Secure nozzles with "Out of Service" bags and nylon ties Verify LOTO is complete by trying to operate pumps <br /> Close ball valves or check valves on product piping. Disconnect electncal "bayonet" connector from the STP(sl <br /> SIGN IN Lead Technician Name ea ien Sqn <br /> General Safety Checks: rJ <br /> All site personnel have been informed / <br /> Fuel delivery has been informed. site Representative Name Me Representative Signature <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. <br /> Work areas barricaded to protect workers, staff & public. I have discussed job clearance form with technician <br /> ✓ POST-TEST PROCEDURES (Check each item completed or mark " it not applicable) <br /> 1- Remove all "LockoutlTagout" devices. <br /> 2. Run all pumps and verify there are no leaks: Impact Valve Test Ports under dispensers <br /> Leak Detector Threads on STP's Functional Elements & Relief Screws <br /> 3. Install lead wire seal on all test plugs & leak detectors that were serviced. <br /> Count LD threads: L1 L2 L3 L4 L5 Lfi <br /> 4- Check following components operational ❑ ATG probes, sensors. & caps <br /> Ball floats, dry breaks & caps ❑ Cathodic protection operational <br /> Containment sumps are dry ❑ Dispensers & POS operational <br /> Dispenser panels are replaced ❑ Drop tubes, fill adapters & caps <br /> Leak detectors & vent tubes ❑ Manhole covers and sump lids <br /> Monitoring system is operational ❑ Shear valves are open <br /> Siphon lines and manifold values ❑ Siphon lines and manifold valves <br /> STP fittings and bayonet connectors ❑ Vents (not capped, plugged or isolated) <br /> 5. Remove barricades <br /> SIGN OUT& Operator verification of Work aVF _ead Technician Name .Ynp-an Sia t e <br /> General Safety Checks: r <br /> Work area has been left tidy & safe. <br /> Site staff are aware of work status including any remaining isolation. Sita eprasentalive dame enialrve Sig_ltuie <br /> Changes to equipment are documented and communicated. <br /> All incidents, near incidents, and unsafe situations reported <br /> site Representative Comments <br /> COMPANY CONFIDENTIAL -0 Tunknulag,% Inc ,201 1. All Rights Reserved. <br /> tinted copies of th-6-ducumont are uncontrolled. I'lic currcnt vcrsion is uvailahl: in the Fanknolo {fin-Linc Documcnt t;ontro S strm- <br />