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e .. <br /> RECENED <br /> Tanknology Inc. 2013 <br /> 8501 N.MoPac Expressway.Suite 400 Austin,TX 78759 (800)964-0010 Policy 100-29-A <br /> JOB CLEARANCE FORM & Rev:D <br /> Revised:"WONMENTAL <br /> SITE SAFETY CHECKLIST-OVF HEALTH PART ENT <br /> Site Name/#: Street Address: W.O.# <br /> Z 2- 9 <br /> l 1 ? Q� �->✓ /yam z 3 r 3 e—' z <br /> Arrival Time: Departure Time: Travel Time: Others on site: Date <br /> _7/�Zj�/ <br /> Scope of W kand Tasks Performed(JSA's must be available for all tasks): - _! <br /> ZIL <br /> Repairs to EqTjpmerq or Parts Provided: <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL pmrrpcTIVE EQUIPMENT REQUIRED(Check items used or mark-if no .a licable <br /> ety Vest Safety Glasses — Gloves Hearing Protection <br /> Steel Toe Boots Splash Goggles Hard Hat _ Other <br /> PRE-TEST PROCEDURES (Check each item completed or mark " if not applicable) <br /> 1. Discuss safety procedures with site personnel. Nearest hospital: �L— <br /> _ <br /> 2. _ Prior to fuel deliveries the U ;ST 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 nozzles with"Out of Service"bags and nylon ties. _j Verify LOTO is complete by trying to operate pumps. <br /> Close ball valves or check valves on product piping. Disconnect electrical"bayonet"connector from the STP(s). <br /> SIGN IN Lead T*nician Name Lead Technician Signature <br /> General Safety Checks: �) <br /> All site personnel have been informed. `� v <br /> Fuel delivery has been informed. Site Representative Name Site Representative ignature <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. ��,,._- <br /> Work areas barricaded to protect workers,staff&public. I have discussed'ob clearance form with technician. <br /> ✓ POST-TEST PROCEDURES (Check each item completed or mark ~ if not applicable) <br /> 1. - Remove all"Lockout/Tagout"devices. <br /> 2. Run all pumps and verify there are no leaks: Impact Valve Test Ports under dispensers <br /> J Leak Detector Threads on STP's -i Functional Elements&Relief Screws <br /> 3. __ 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 /> Containment sumps are dry Dispensers&POS operational <br /> L� Dispenser panels are replaced Drop tubes,fill adapters&caps <br /> -1 Leak detectors&vent tubes Manhole covers and sump lids <br /> 1 Monitoring system is operational Shear valves are open <br /> Siphon lines and manifold valves r' Siphon lines and manifold valves <br /> STP fittings and bayonet connectors Vents(not capped,plugged or isolated) <br /> 5. Remove barricades. <br /> SIGN OUT&Operator Verification of Work(OVEJ Lead Technician Name L Technician Signature <br /> General Safety Checks: <br /> Work area has been left tidy&safe. <br /> Site staff are aware of work status including any remaining isolation. Sitd 5,%pr4sentative Name site epr entativ Sign u <br /> Changes to equipment are documented and communicated. j <br /> All incidents,near incidents,and unsafe situations reported. <br /> Site Representative Comments: <br /> COMPANY CONFIDENTIAL C Tanknology Inc..2011.All Rights Reserved. <br /> rimed copies of this document are uncontrolled. The current version is available in the Tanknoloe•On-Linc Document Control S stem. <br />