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W.O.# AST-6700447 <br /> Tanknology Inc. <br /> 11000 N.MoPac Expressway,Suite 500 Austin,TX 78759 (800)9640010 Policy 100-29-A <br /> A JOB CLEARANCE FORM& Rev <br /> d:1/24/2014 <br /> SITE SAFETY CHECKLIST-OVF <br /> Sit Namef#: Street Address: W.O.# <br /> K <br /> off' g7oq �Jc, u- v zooq 7 <br /> Arritlat Time: Departure Time: Travel Time: Others on sit : Date <br /> Scope of Work and Tasks P rformed(JSA's must be available for all tasks): <br /> ��Cti'� <br /> Repairs to Equipment r Parts Provided: <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIR Cheek items used or mark-if notapplicable) <br /> Safety Vest Safety Glasses Gloves ❑ Hearing Protection <br /> Steel To Boots I ❑ Splash Goggles ❑ Hard Hat ❑ Other <br /> ✓ PRE-TEST PROCEDURES Check each item completed or mark — if not applicamble <br /> 1. ❑ 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 /> 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 perate pumps. <br /> ❑ Close ball valves or check valves on product piping. ❑ Disconriect electrical"bayonet"c4nn4qtor from the STP(s). <br /> A Le7dic! Na` ad Technician Signature <br /> General Safety Checks: eAll site personnel have been informed. 1tJf/h <br /> Fuel delivery has been informed. Site Representative Name Re R resen�trve Signature <br /> Is a fuel delivery due today? /r � <br /> LOTO procedures have been discussed and agreed. L_ S a <br /> Work areas barricaded to protect workers,staff&public. <br /> ✓ POST-TEST PROCEDURES(Check each item completed or mark "r if not applicable) <br /> 1. ❑ Remove all"Lockoutrragout"devices. <br /> 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under if <br /> ❑ Leak Detector Threads on STD'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— L6 <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 valves ❑ Siphon lines and manifold valves <br /> ❑ STP fittings and bayonet connectors ❑ Vents(not capped,plugg isolated) <br /> 5. ❑ Remove barricades. <br /> Le tj ead Technician Signature <br /> xGeneral Safety Checks: <br /> Work area has been left tidy&safe. <br /> Site staff are aware of work status including any remaining isolation- Representative Na ReRep ntative signature <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. 40 <br /> Site Representative Comments: <br /> COMPANY CONFIDENTIAL ©Tanknology Inc.,2011.All Rights Reserved. <br /> rinted copies of this document are uncontrolled. The current version is available in the Tanknology On-kine Document Control System <br />