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W.O.# AST-6703016 <br /> Tonknology Inc. <br /> now," 'btu.. Fapressway,Suite 500 Austin,TX 78759 (800)964.0010 Polley 100-29-A <br /> JOB CLEARANCE FORM& Rev:D <br /> Revised:1/24/2014 <br /> SITE SAFETY CHECKLIST-'OVF <br /> Site Name4k. StrettAddress: # <br /> 4OZ& 7-0 711 Z4 <br /> Arrival Time: I rjDjepMrbze2TrnV Travel Time: Others on site: ata <br /> pe of Work and Tasks P ( `8 must 1�available for all tasks): <br /> Repairs to't=quipment or Parts Provided: <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PRSrECTIVE EQUIPMENT REQUIRED Check trema used or mark-If not Met/cable) <br /> ty Vest Safety Glasses Gloves ❑ Hearing Protection <br /> Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other <br /> ✓ PRE-TEST PROCEDURES(Check each Item comotetod or mark—ifnot asa/kaibtel <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 Lockout(Tagout 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 noaales 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 electrical"bayoust"oonnector from the STP(s). <br /> Lead ._ <br /> clan Nero edmidan signature <br /> General Safety Checks: <br /> All site personnel have been informed. <br /> Fuel delivery has been informed. Me Kepresentau-Rerre gni re <br /> Is a foal delivery due today? <br /> LOTO procedures have been discussed and agreed. <br /> Work areas barricaded to protect workers,staff&public. <br /> I have discussed bclearance-form With technician. <br /> ✓ POST-TEST PROCEDURES tCheck each ftem comofeled or mark~If not a wNe- -tel <br /> 1. ❑ Remove all"LockouttTagout"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. �j 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 /> i✓ 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,plugged or isolated) <br /> 5. ❑ Remove barricades. <br /> Lead Technician Name re <br /> General Safety Checks: 7/ <br /> Work area has been left tidy&safe. k,, t -Ar <br /> G <br /> Site staff are aware of work status including any remaining isolation. tM KePrOWreeve erre to nature <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. <br /> Site ffi: <br /> COMPANY CONFIDENTIAL ®Tanlmology Inc.,2011.All Rights Reserved. <br /> les of this document are uncontrolled.The current version is available in the Tanknoi On-Line Document Control S <br />