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W . O . # NW1 - 2338728 Cust Ref # : COCO - 0015297489 <br /> Tanknotogy Inc. <br /> I I lOOO N . MaPac Fxpress% ay, $cite 5OO Austin, TX 78759 (800) 964-(1010 Policy I (afi ?9-A <br /> JOB CLEARANCE FORM & Rev: D <br /> Revised: 112412014 <br /> SITE SAFETY CHECKLIST - OVF <br /> Site NOMOC Or Street Address: W.O. # <br /> rskoc� o r, 'L (" 3 <br /> Arrival Time: Departure Time: Travel Time: Others onsite: Date <br /> adoIAItvv,Ai4 <br /> Scope of Work and Tasks Performed (JSA's must be available for all tasks): <br /> Repairs to Equipment or Parts Provided: <br /> Follow-up actions required; equipment isolated; comments: '.. <br /> PPE - PERSONAL PROTECTIVE EQUIPMENT REQUIR D Check items used or mark — N notapplicable) <br /> Safety Vest Safety Glasses Gloves ! Hearing Protection <br /> _ Steel Toe Boots 1 Splash Goggles Hard Hat _€ Other <br /> ✓ PRE-TEST PROCEDURES (Check each item completed or mark H not applicable) <br /> 1 . T - Discuss safety procedures with site personnel. Nearest hospital: <br /> 2 Prior to fuel deliveries the UST system must be placed back into working order. <br /> 3. r Secure entire work area with barricades (cones, flags, and caution tape, pennant flags , or other perimeter guard) . <br /> 4. f Place fire extinguishers and `No Smoking' signs in the work area. <br /> 5. implement LockouVTagout per API 1646 (when accessing product piping during tasks) <br /> Ail 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. Venty LOTO is complete by trying to operate pumps <br /> Close ball valves or check valvas on product piping. Disconnect electrical bayonet' connector from the STP(si. <br /> SIGN IN Lead lectOvan Nw4o Lead r Sgnalare <br /> General Safety Checks: <br /> All site personnel have been informed . i r <br /> Fuel delivery has been Informed, a eFresenaam Name a RepresentaL}ro ;naw e i <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. , t L« �✓L� GJ--^C <br /> i <br /> Work areas barricaded to protect workers, staff & public. l have discussed job clearance form with technician . <br /> ✓ POST- TEST PROCEDURES (Check each item completed or mark if not applicable) <br /> 1 Remove all "Lockoutlfagout" devices. <br /> 24 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. Install lead wire seal on ail test plugs & leak deteciors that were serviced. <br /> Count LD threads: Lt _ L2 _ L3 _ U - L5 _ 1.6 _ <br /> 4 . Check following components operational: 1 ATG probes , sensors, & caps <br /> Ball floats, dry breaks & caps Cathodic protection operational <br /> J Containment sumps are dry rr Dispensers & POS operational <br /> r Dispenser panels are replaced Drop tubes, fill adapters & caps <br /> Leak detectors & vent tubes i}Z Manhole covers and sump lids <br /> Monitoring system is operational It 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 isolated ) <br /> 5 . t i Remove barricades. <br /> SIGN OUT'& Operator Verification of Work OVF d Lead oOmnan ams Lead reJ assn mature <br /> General Safety Checks: <br /> Work area has been left Udy & safe.Site staff are aware of work status Including any remaining Isolation , Sao Representative rtatne sae Re Ie tativa ,nal <br /> Changes to equipment are documented and communicated. <br /> All incidents, near incidents, and unsafe situations reported. <br /> efle,nieniame cerrunen!s: <br /> orma AWA chit 6 on �td <br /> COMPANY CONFIDENTIAL 9 ' �yy� r tY a' Tnnknoloo Inc., 2011 . All Riglits Reserved. <br /> rinted cepies of this document are uncontmllcd. ` `he cum:ht vei'sinn Is available in the Tankno!aL On-line Document Control System <br />