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Tanknology Inc. Policy 100-29-A <br /> 8501 N.MoPac Expressway,Suite 400 Austin,TX 78759 (800)964 X10 Rev:D <br /> JOB CLEARANCE FORM & Revised:8/04/2009 <br /> SITE SAFETY CHECKLIST — OVF <br /> Site Namel#: Street Address: W.O. <br /> j5v" 7l� 1/d3 S. A <br /> rrival Time: Departure Time: Travel Time: Others on site: ®StA <br /> 2i � 17 : 05 11 0 1 -1 115 <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): C <br /> O /lG� NS /y'94� <br /> Repairs tcf Equiprrrentor Parts Provided-IeJ�04A:60 an/ VX- i..tS-44 <br /> t.16® 6%4L, ui 1 Eiu, I Lr RO r lL <br /> Follow-up actions requi ;equipment isolated;comments: <br /> Lio'-9- 130i l - S' Co <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIREDCheck Items used or many-if not likable <br /> Safety Vest Ai� Safety Glasses t9- Gloves ❑ Hearing Protection <br /> Steel Toe Boots t>k.. Splash Goggles 1 ❑ Hard Hat ❑ Other <br /> ✓ E TEST PROCEDURES &Check each item completed or mark — if not applk/abble) <br /> 1. @� Discuss safety procedures with site personnel. Nearest hospital: RXao ot <br /> .5.0n , of /"/ � <br /> 2. Prior to fuel deliveries the UST system must be placed back into working order. —F'13- 311 <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. ❑ 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 /> Lead echniaan ams Lead I echrvaqri Signature <br /> General Safety Checks: <br /> AI!site personnel have been informed. ' <br /> Fuel delivery has been informed. S �� / <br /> is a fuel delivery due today? Site Representative Name pre Repress. sgnature <br /> LOTO procedures have been disc ssed and agreed. C <br /> Work areas barricaded to protect workers,staff&public. <br /> I have discussed Job clearance fort.with technician. <br /> ✓ POST-TEST PROCEDURES(Check each item completed or mark ^ :f not se2Ecabte2 <br /> 1. ❑ Remove all"Lockoutfragout"devices. <br /> 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers <br /> Leak Detector Threads on STP's ❑ Functional Elements&Relief Screws <br /> 3. 11 Install lead wire seal on all test plugs 8,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 /> Dispenser panels are replacedDrop tubes,fill adapters&caps <br /> Leak detectors&vent tubes Manhole covers and sump lids <br /> Monitoring system is operational Shear valves are open <br /> Siphon lines and manifold valves ISiphon lines and manifold valves <br /> STP fittings and bayonet connectors Vents(not capped, plugged or isolated) <br /> 5. Re cove barricades. <br /> Lead Technician Name Lead Technida0 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. site Rep ntative Name Represen lure <br /> Changes to equipment are documented and communicated. "� <br /> 4. <br /> All incidents,near incidents,and unsafe situations reported. 7j (/''1or <br /> its Representative Comments: <br /> COMPANY CONFIDENTIAL <br /> rinted copies of this document are uncontrolled. The current version is availan thO Tanknology Inc„2011.All Rigbts Reserved. <br /> ble ie Ta <br />