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W.O.# NW1-2314881 Cust Ref#: PO #0015140464 <br />Tanknology Inc. <br />> <br />9501 N. MoPac 5xptvssasy, Suitc 4)9 Austin, TX ?8754 (8W),9644*14 Policy 100- 9-A <br />JOB CLEARANCE FORM &R"`: ° <br />ft�><i�ed: 8t0412008 <br />SITE SAFETY CHECKLIST — OVF <br />ife ame : <br />W9k 144;;�g <br />street Aaress., t <br />W.O. # <br />Arrival Time: Departure Time: <br />a Time. Others on site: <br />Daae <br />?.S'_0 <br />Scope of ork and`�`ask�s 'r ad (JSA' must be avaitabie tar 'ati <br />epair toEquipmenor artsProvi <br />(i <br />f ollow-up actions requir ; egvi ' nt isolated; comments; <br />PPE • PERSONAL PROMC77VE EQUIPMENT YEQtf1R hick items used or mark — N nota icabte <br />etyVast Safety GSlasse$ C3k+ves <br />' tiaarinyPratection <br />SteatToe B s Splash Goggles Nard Nat <br />Other <br />✓ PRE TEST PROCEDURES ICheek each ftem completed or mark — If not apolfcabfe9 <br />1. D' ss safety procedures with site personnel, Nearest hospital <br />2.to fuel deliveries the UST system must be placed back into working order. <br />3. ure entire work area with barricades (crones, flags, tape, <br />and caution pennant flags; or other perimeter guard), <br />4. Piac rt extinguishers and "Ido Smoking" signs in the work area <br />5. t em nt LockouttTagout per API 1646 (when accessing p uct pi ' g during tasks) <br />applicable equipment disabled during test(s). S e the circuit breaker(s) with lockout devices and tags, <br />�. <br />Secure nozzles with 'Out of Service" bags and nylon tie Verify LOTO is complete by trying to rate limps. <br />Close ball valves or Check valves on product piping. Done eleGtrgat "hti onet anon for fro the STP(s). <br />SIGH+! W - <br />Load nacho n # a4 nWanS knatum <br />jia, <br />General Safety Checks: <br />AD site personnel have been informed. <br />Fuel delivery has been informed. <br />Is a fuel delivery due today? <br />Size eprese t we Nanta epresaatatry ,Sl nom ire <br />� ' <br />LOTO procedures have been discussed and agreed.�tio <br />r . . <br />Work areas barricaded to protect workers, staff & public, <br />l have iscusscrf 'ob clearance form with technician, <br />POST TEST PR0CEQURES L heck each Item comnfeted or mark " tf nota !/caGle <br />1. ve all "LockoutlTagout" devices. <br />2 � Run afl pumps and verify there are no leaks; Impact Valve Test Psrts under dispensers <br />Leak Detector Threads on STP's Functional Elements & Relief Screws <br />3, t lead wire seal on all test plugs &teak detectors that were serviced. <br />Count LD threads: L1 —L2 ___, L3 L4 L6 <br />_ <br />4. Check following components operational; ATG probes, sensors, & caps <br />BIBliAoats, dry breaks & capso is protection operational <br />dry <br />tnment sumps are Dispensers & PCIS operational <br />Dispa r panels ars replaced' [arc hes, Ilii adapters &caps <br />detectors & vent tubes le covers and sump lids <br />Monitoring system is operational Shear valves are open <br />Siphon lines and manifold valves Siphon lines and manifold valves <br />STP fittings and bayonet connectors Vents (not capped, plugged or iso d) <br />S. Remove barricades, <br />„ ...' '7 - i,l' ,�rdoY Wetlficatlon of Work- --` �. d TeshrS...n <br />- a - euitnlrfsn Sigttatvre. <br />General Safety Checks - <br />;—V <br />Work <br />Work area has been left iidy & safe { n <br />Site Staff are aware of work status including any remaining is,.iiation, s>i arirosoi tau" Norm <br />v <br />to ,a Mat:- mare <br />tu <br />Changes to equipment are documented and communicated, <br />All incidents, near incidents, and unsafe situations raported. t <br />iteRepresen Iver omnwnw. <br />COMPANY CO;ti;``IDENTi.AL C; 701knoloU Inc., 2011. All flight, Rmmved. <br />_... <br />toted e iec of this docuinmt .ire uij�ontrolled, I he e.urmm version k available in the Tanknolo t7n-Line 2Jgevrneni Control S'stom� <br />