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Work Order: 2255812 <br />Tanknology Inc. l Policy 100.29-A <br />$501 N. MUNW Expressway, Suite 400 ALL-AK'rX 7M9 [rev: B <br />Phnec.(Rf10)%4-00l0Local: f.npt:(St2)451-6334 I Reviscd;1110MUU6 <br />SITE SAFETY CHECKLIST & Page 1 00 <br />OPERATOR VERIFICATION FORM <br />Site Name: p <br />Address; <br />W.Q. p <br />Saa Representative Name <br />Cz�,7 <br />Clt'eke <br />ZZY5sqvZ- <br />sites : <br />1 Scfr{� <br />OWSTrzip: <br />Dose: <br />Scope of Work: <br />Parts & Meleney Provided: <br />AWwA <br />�V <br />Departure Time <br />Travel Time: <br />Y�� <br />1. U Discuss oafeiy procedures with site personnel. <br />2. T Prior to fuel deliveries, the complete tank <br />system to be placed back into working order. <br />3. 7 Secure senile work area with cones, flags, and <br />caution tape or pennant Flags. <br />4. v Place fire eAnquishers and 'No Smoking" <br />signs in the worst area. <br />5- ❑ "All applicable pumps: dispensers, and <br />electrical breakers mutat be disabled during the <br />test(s). <br />6. — *Tum off and secure the circuit breaker(s) with <br />lockout devices and tags. <br />7. f *Place "Out of Service bags and nylon ties on <br />dispenser nozzles. <br />8- . ii *Verify LockouttTagout procedure is complete <br />by trying to operate purnps. <br />9. : I *Close ball visives or check valves on product <br />piping. <br />1U. C "Remove the electrical 'bayonet' connector <br />from the 8TP(s). <br />• %ackout/Tagout applies when acoessing product piping <br />Nearest hospital: li11 <br />1, _ Remove all°LockauMTagrwt" devices, <br />2. - Run all pumps and verify there are no leaks <br />under dispensers or in STP Sumps. <br />Impact Valve Test Por! <br />Leak Detector Threads <br />Functional Element & Relief Screw <br />3. _ Install a lead wire seal on all test plugs & leak <br />detectors that were serviced. Count LO threads: <br />L1 _ . L2 _ L3 _ L4 L5 _ <br />4. Ensure that alt tank system components are <br />resfnred to their original state (including); <br />- ATG probes, sensors, & caps <br />- Ban floats, dry breaks & caps <br />• Cathodic protection operaponal <br />Cordainment sumps are dry <br />• Dispensers & POS operational <br />Dispenser panels are replaced <br />Drop tubes, fill adapbrs & caps <br />Leak detectors & vent tubes <br />Manhole covers and sump lids <br />Monitoring system is operational <br />Shear valves ane open <br />Stphan lines and manlold valves <br />• Spill containers & drain valves <br />STP 511ings and bayonet connectors <br />5. Remove cones, sins, and caution lope- <br />TankrwtogyTerArticianName <br />Pre add est lure <br />Saa Representative Name <br />Te atvnt Post -Test S' ature <br />RA <br />f <br />~ --r— 7�t� <br />Comments: <br />i <br />tAl►1i'ANY CXRWIDUMAL V Tanktmbgy lac.. 2006. A11 Rights Rewrved <br />ted curpies of [iris &MMeffE air eoroataolled. The cwmnt vtaxl m Is available is the Taokaobgy Qn ! ice lka:ument t.mtmi Svetcm <br />Tanknology Inc. 8501 N. MoPac Expressway, Suite 400, Austin, Texas 78759 <br />