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0 <br /> Tanknology Inc. <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:8/04/2008 <br /> SITE SAFETY CHECKLIST—OVF <br /> Site Name/#: Street Address: W.O.# <br /> ell 7 S � t')10 e'-73071 1----7 <br /> Arrival Time: Departure Time: Travel Time: 10thers on site: Date <br /> q .'00 /-7 : 00 <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): <br /> '4 .5se <br /> Repairs to ftipmenf or Parts/Provided: <br /> Foll -up actions <br /> required;equipment isolated;comments: <br /> c,(C�/ <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark-if not licable <br /> Safety 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: -FU -/LAC S� /�'�� <br /> 2. Prior to fuel deliveries the UST 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. iCK Implement Lockout/Tagout per API 1646(when accessing product piping during tasks) <br /> (X 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. 9W-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 Technician Name Lead Technician signature <br /> General Safety Checks: l! <br /> All site personnel have been informed. J <br /> Fuel delivery has been informed. Site Representative Name rte R nta a Signature <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discu and agreed. <br /> Work areas barricaded to protect workers,staff&public. have discussed'job clearance form withtechnician. <br /> ✓ POST-TEST PROCEDURES(Check each item completed or mark -• if not applicable) <br /> 1. i>C Remove all"Lockout/Tagout"devices. <br /> 2. CV,� Run all pumps and verify there are no leaks: Ci<� Impact Valve Test Ports under dispensers <br /> F Leak Detector Threads on STP's C Functional Elements&Relief Screws <br /> 3. ❑ Install lead wire seal on all test plugs&leak detectors that were serviced. <br /> Count LD threads: L1 1-2 L3 L4 L5 L6 <br /> 4. CK Check following components operational: ATG probes,sensors, &caps <br /> Ball floats,dry breaks&caps ❑ Cathodic protection operational <br /> Containment sumps are dry 4i�( Dispensers&POS operational <br /> Dispenser panels are replaced Drop tubes,fill adapters&caps <br /> Leak detectors&vent tubes Manhole covers and sump lids <br /> Monitoring system is operational irr Shear valves are open <br /> ItSiphon lines and manifold valvesSiphon lines and manifold valves <br /> STP fittings and bayonet connectors ents(not capped,plugged or isolated) <br /> 5. Remove barricades. <br /> Lead Technician Name >Lead Technician Signature <br /> General Safety Checks: <br /> Work area has been left tidy&safe. JT�/.6j t, aw <br /> Site staff are aware of work status including any remaining isolation. Site Representative Name --§0 Rep sentati nature <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. r r:ch <br /> Site Representative Comments: <br /> COMPANY CONFIDENTIAL ©Tanlmology Inc.,2011.All Rights Reserved. <br /> rinted copies of this document are uncontrolled. The current version is available in the Tanknolo On-Line Document Control System] <br />