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0 0 <br /> W.O.# NW1-2314890 Cust Ref#: PO: 0015114456 <br /> ......... <br /> Tanknology Inc. , <br /> 8St)i tis.MoPac GnprL,,,sway,Suite 4(X)AuS,in.TX?9759 (goo)y(1d)!)IU Aoticy 100-29-. <br /> .IUB CLEARANCE FORM & Rev:p <br /> Revise&6((}4/28 <br /> SITE SAFE'T'Y CHECKLIST--UVF <br /> -------------------- <br /> SE Name!#: Street Address: .. -�.. <br /> Q64rj1J i[ <br /> Arrival Time: Departure Time: Travel Time: Oth ra an site: [sate <br /> Scope of Work and Tasks Performed(JSA's rust be available for all tasks): <br /> L S 6i 2 A4l'V> c.YJ, Pr�C,, <br /> Repe rs to Equipment or Parts Provided. <br /> Follow-up actions required;equipment isolates;comments: <br /> �T-B. <br /> E•PERSON.4t P CINE EC?t1dP�EtdT R'EQUPRED ck items used or mark-if not a icabfe <br /> � Safely Glasses Gloves Hearing Prataetian <br /> 2St-1 s Splashgglss Haret Nat M Other <br /> *� PR,�-�E*i�PRUCEQUi�tF.S (Ctreck each item cora Meted or mark ^"if a7oi aaxx8doabte) �--- <br /> 1. Discuss safety procedures with site personnel. Nearest hospital: <br /> 2. Prior to fuel deliveries the UST system must be placed hack 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 Lockouttl agout per API 1645(when accessing product piping during tasks) <br /> All applicable equipment disabled during testis), Secure the circuit breaker(s)with lockout devices and tags. <br /> Secure nozzles with"Out of Service"bags and nylon ties. l._' verify LOTO is complete by trying t o,grate pumps. <br /> J Close bail valves or cheek valves on product piping. isconn t electrical"bayonet'ca ec r from the S T P{s)• <br /> ;��`l f Lead Tech as oma Le T e0winan yignaltre <br /> General safety Checks. <br /> All site personnel have been informed. <br /> Fuel delivery has been informed. Site Representative Nanta .s: ep,ewntai"e signature <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discuss d and agreed. ti i ey <br /> Work areas barricaded to protea workers,staff&public, have discussed jot.ciC ora cs`arm with technician. <br /> ./ <br /> POST-TES T PROCEDURES(Check each item completed or marts — if'not appfdcatrte� <br /> 1. Remove all`LockoutlTagout"devices. <br /> 2. 1 Run all pumps and verify there are no leaks: impact Valve Test Ports Under dispensers <br /> Leak Detector Threads on STP'" Functional Elements&Relief Screws <br /> S. Install lead wire seal on all test plugs&leak detectors that were serviced. <br /> Count LO threads 1-1 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 <br /> Drop tubes,fill adapters&caps <br /> Leak detectors&vent tugsManhole savers and sump lids' <br /> Monitoring system is operational Shear valves are open <br /> Siphon lines and manifold valves Siphon Pines and manifold valves <br /> STP fittings and bayonet connectors Vents(not capped,plugged o, 'solated) <br /> 5, Remove barricades, <br /> 1G .1t1UT& dttRpatlmca er!iAltuk (illi aaL i. <br /> General Safety Checks: <br /> Work area has been lett tidy&safe. <br /> Site staff are aware of work status including any remaining isolation. s s e esenut,•,c,vac, l nH rearesar ,iv si,atom <br /> Changes to equipment are documented and communicated. �p <br /> All inddents,negrincioonts,and unsafe wtuatroes rmpcAed, l" <br /> site rZepm—iiat-C—in-L-E <br /> COMPANY CONFIDENTIAL rattknoiot}inc...2011.All Pigh s Re :cert. <br /> ......I <br /> [':vrint. ,pies ezf this document am uncsai tx lied T h� urrcnt�. ',inn i�w :,rbk in rhe Taxihxaula}.Un Eirw I)o-caxrimt contrr 1 scoter, <br />