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0 l 0 <br />Site Name/# <br />Tanknology Inc. <br />„ 11000 N. tvlopac Lspressway, Suite 500 Aust <br />n, TX 78759 (800) 964-0010 <br />Policy 100-21-A <br />Rev: D <br />.TOB CLEARANCE <br />FORM & <br />Revised: 1/24/2014 <br />4410 <br />SITE SAFETY CHECKLIST <br />- OVF <br />Date <br />Site Name/# <br />Street Addres <br />: <br />W.O. # <br />%1 <br />Arrival Time: Departure Time: <br />Travel Time: <br />Others on site: <br />Date <br />1 <br />-2��} <br />Scope of Work and Tasks Performed (JSAs must be available for all tas <br />s): <br />/ . r " <br />Repairs to Equipmen or Parts Provided: <br />Follow-up actions required; equipment isolated; comments: <br />PPE - PERSONAL PROTECTIVE EQUIPMENT REQU <br />RED Check items used or mark — If not geiplicabLej <br />o fety Vest <br />Safety Glasses <br />+ Gloves <br />Hearing Protection <br />I <br />Steel Toe Boots <br />Splash Goggles <br />ti Hard Hat <br />Other <br />✓ PRE-TEST PROCEDURES cack <br />each item completed or mark ^ ifnotapplicablej <br />1. _=: Discuss safety procedures with site personnel. Neare <br />hospital: <br />3ack into working order. <br />2. Prior to fuel deliveries the UST system must be placed <br />3. _' Secure entire work area with barricades (cones, flags, <br />nd caution tape, pennant flags, or other perimeter guard). <br />4. Place fire extinguishers and "No Smoking" signs in the <br />Nork area. <br />5. _ Implement Lockout/Tagout per API 1646 (when acre <br />ng product piping during tasks) <br />All applicable equipment disabled during test(s). <br />❑ Secure the circuit breaker(s) with lockout devices and tags. <br />Secure nozzles with "Out of Service" bags and nylon ties. <br />❑ Verify LOTO is complete by trying to operate pumps. <br />Close ball valves or check valves on product piping. <br />Disconnect electrical "bayonet" connector from the STP(s). <br />SIGN IN <br />lead Technician Name <br />Lead Technician Signature <br />General Safety Checks: <br />All site personnel have been informed. <br />_ „a <br />, <br />Fuel delivery has been informed. <br />Site R <br />f e gnature <br />Is a fuel delivery due today? <br />LOTO procedures have been discussed and agreed. <br />Work areas barricaded to protect workers, staff & public. <br />rI have discussed job clearance form With technician. <br />✓ POST TEST PROCEDURES <br />Check each Item com feted or mark ~ if nota licable <br />1. ❑ Remove all "LockoutiTagout" devices. <br />2. ❑ Run all pumps and verify there are no leaks: <br />❑ Impact Valve Test Ports under dispensers <br />Leak Detector Threads on STP's <br />U Functional Elements & Relief Screws <br />3. ❑ Install lead wire seal on all test plugs & leak detector <br />that were serviced. <br />Count LD threads: L1 L2 L3 <br />L4 L5 L6 <br />4. ElCheck following components operational: <br />ATG probes, sensors, & caps <br />❑ Ball floats, dry breaks & caps <br />❑ Cathodic protection operational <br />❑ Containment sumps are dry <br />❑ Dispensers & POS operational <br />El Dispenser panels are replaced <br />❑ Drop tubes, fill adapters & caps <br />❑ Leak detectors & vent tubes <br />© Manhole covers and sump lids <br />Monitoring system is operational <br />❑ Shear valves are open <br />Siphon lines and manifold valves <br />❑ Siphon lines and manifold valves <br />STP fittings and bayonet connectors <br />❑ Vents (not capped, plugged or isolated) <br />5. Remove barricades. <br />SIGNOUT & O e dI1 Of Work t)1IF <br />Lead Technician Name <br />lead TechnidarrSignature <br />General Safety Checks: <br />Work area has been lefttidy & safe. <br />Site Representative Name <br />Site Rep"tative Signature <br />Site staff are aware of work status including any remaining isolation. <br />Changes to equipment are documented and communicated. <br />t <br />All incidents, near incidents, and unsafe situations reported. <br />Site Representative Comments: <br />v <br />COMPANY CONFIDENTIAL <br />6 Tanknology Inc., 2011. All Rights Reserved. <br />(printed conies of this document are uncontrolled. "flee current versign is avituame m me t anxncuogy tin-r.inu jJMUrFic,u —,u- JY—"j <br />