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• • W.O.# AST-6703016 iTanknology Inc. 11000 N.MoPac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Policy 100-29-A JOB CLEARANCE FORM& Rev:D 4 4W SITE SAFETY CHECKLIST-OVF Revised:184/2014 Site Name!#: Street Address: 9O/ ogAr- yo,Q12,4 w•4y W.O.# P — L S33D (070 � Arrval Time: DeiSA ure Tim ravel Time: Others on site: Date s6� Scope of Work and Tasks Prtl 's must be7-12 available for all tasks): G T Repairs to Equipment or Parts Provided: Follow-up actions required;equipment isolated;comments: PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check Items used or mark-N not applicable) Safety Vest Safety Glasses Gloves ❑ Hearing Protection k Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other ✓ PRE-TEST PROCEDURES (Check each item comnfeted or mark ^ if not applicable) 1. ❑ Discuss safety procedures with site personnel. Nearest hospital: 2. ❑ Prior to fuel deliveries the UST system must be placed back into working order. 3. ❑ Secure entire work area with barricades(cones,flags,and caution tape,pennant flags,or other perimeter guard). 4. ❑ Place fire extinguishers and"No Smoking"signs in the work area. 5. ❑ Implement Lockout(fagout per API 1646(when accessing product piping during tasks) ❑ All applicable equipment disabled during test(s). ❑ Secure the circuit breaker(s)with lockout devices and tags. ❑ Secure nozzles with'Out of Service"bags and nylon ties. ❑ Verify LOTO is complete by trying to operate pumps. ❑ Close ball valves or check valves on product piping. ❑ Disconnect electrical"bayonet"connector from the STP(s). SIGN IN Lead Technician Name Techngnaure General Safety Checks: All site personnel have been informed. �— Fuel delivery has been informed. lure Is a fuel delivery due today? site Itepresentative Name LOTO procedures have been discussed and agreed. Work areas barricaded to protect workers,staff&public. I have discussed'ob clearance form with technician. ✓ POST-TEST PROCEDURES(Check each Item completed or mark if not applicable) 1. ❑ Remove all"Lockout/Tagout"devices. 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers ❑ Leak Detector Threads on STP's Cl Functional Elements&Relief Screws 3. ❑ Install lead wire seal on all test plugs&leak detectors that were serviced. Count LD threads: Li_ L2_ L3_ L4_ L5_ L6_ 4. ❑ Check following components operational: ❑ ATG probes,sensors,&caps ❑ Ball floats,dry breaks&caps ❑ Cathodic protection operational ❑ Containment sumps are dry ❑ Dispensers&POS operational ❑ Dispenser panels are replaced ❑ Drop tubes,fill adapters&caps ❑ Leak detectors&vent tubes ❑ Manhole covers and sump lids ❑ Monitoring system is operational ❑ Shear valves are open ❑ Siphon lines and manifold valves ❑ Siphon lines and manifold valves ❑ STP fittings and bayonet connectors ❑ Vents(not capped,plugged or isolated) 5. ❑ Remove barricades. SIGN OUT&OpaiatorVerification of Work"OVF Lead Technician Name nature General Safety Checks: Work area has been left tidy&safe. Site staff are aware of work status including any remaining isolation. Site/Representauve Name nWrvesignature Changes to equipment are documented and communicated. All incidents,near incidents,and unsafe situations reported. Site Representative Comments: COMPANY CONFIDENTIAL C Tanknology Inc.,2011.All Rights Reserved. Printed copies ofthis document are uncontrolled. The current version is available in the Tanknol On-Line Document Control S stem.