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Tanknology Inc. 11000 N. MoPac Expressway, Suite 500 Austin, TX 78759 (800) 964-0010 t • Policy 100-29-A Rev: D JOB CLEARANCE FORM & Revised: 1/24/2014 SITE SAFETY CHECKLIST — OVF Site Name/#: Street Address:W.O. /��Oy5 # 0119 /ZG1Y 33-1 Arrival Time: Departure Time: Travel Time: Others on site: Date 1q, ID Scope of Work and Tasks Performed (JSA's must be available for all tasks): T Repairs to Equipmen or Parts Provided: rjU.—%tjt"j V ROD Follow-up actions required; equipment isolated; comments: PPE -PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark —if ndt Arlo Wety Vest Q Safety Glasses C4 --Gloves ❑ { Ft ri r tection L� Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other ✓ PRE-TEST PROCEDURES (Check each item completed 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/Tagout 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). I MIN- a77 4 7�, . s a. . 9� � , � � � Lead Technician Name d Technician Signature �.._.. /1 General Safety Checks: All site personnel have been informed. j 1 r Fuel delivery has been informed. SitO Represen a Name n e e ignature Is a fuel delivery due today? LOTO procedures have been discussed and agreed. � � t � c� / � ,v Work areas barricaded to protect workers, staff & public. I have discussed job clearan&4orm 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 ❑ Functional Elements & Relief Screws 3. ❑ Install lead wire seal on all test plugs & leak detectors that were serviced. Count LD threads: L1 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. Lead Technician Name ,--%T chnici ignature ' General Safety Checks: r Work area has been left tidy & safe. = 1 Site staff are aware of work status including any remaining isolation. Site presentative Name ite p tative Signature Changes to equipment are documented and communicated. -D 16o.115 All incidents, near incidents, and unsafe situations reported. Site Representative Comments: COMPANY CONFIDENTIAL © Tanknology Inc., 2011. All Rights Reserved. Vrinted copies of this document are uncontrolled. The current version is available in the Tanknology On -Line Document Control System