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W.O.# NW1-2348303 Cust Ref# : COCO-0015345128 / p treat Ad ress: w' ' p Sile�ame/a: it / (� 1 7. -i Gi, r . .•7 "f I A Z -/ u COMPANY CONFIDENTIAL © Tanknology Inc., 2019. All Rights Reserved. rinted copies of this document are uncontrolled. The current version is available in the Tanknoloa On-line Document Control S stem. Ovf er on 911e: Date Am-] Time: Departure Time: Travel Time: Scope of work and Tasks Performed (JSA's must be ava1ila'ble for all, tasks): Repairs to Equipment or Parts Provided: Follow-up actions required: equipment isolated; comments: PPE- PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check ✓items used or mark -if notapplicable) Safety Vest � Safety Glasses Gloves ❑ Hearing Protection Goggles ❑ Hard Hat ❑ Steel Toe Boots ❑ Splash Other PRE-TEST PROCEDURES (Check -,each item completed or mark -- if not applicable) /✓ �L safety procedures with site personnel. Nearest hospital: 7/1 1. lscuss 'to fuel deliveries the UST system must be placed back into working order. 2.�Piacerfire 3.e entire work area with barricades (cones, flags, and extension bars, caution tape, pennant flags, or other perimeter guard). 4. extinguishers and "No Smoking" signs in the work area. 5. ❑ _ Confined Space Entry - If required complete separate CSE Checklist. If NO CSE REQUIRED check the following reason: ❑No CS's ❑CS's not opened []No entry only visual ❑No entry - used tools []Work from prone position Wo risk of falling in 6. ❑ Implement LockouVTagout per API 1646 (when accessing product piping during tasks) ❑ Secure nozzles with "Out of Service" bags and nylon ties. ❑ Secure the circuit breaker(s) with lockout devices and tags. ❑ Close ball valves or check valves on product piping. ❑ Disconnect electrical "bayonet" connector from the STP(s). ❑ All applicable equipment disabled during test(s). ❑ Verify LOTO is complete by trying to operate pumps. SIGN IN lead Technician Name Lead Technician Signature General Safety Checks: �(7 All site personnel have been informed. J r Is a fuel delivery due today? Site Representative Name Site Representative Signature LOTO procedures have been discussed. Work areas barricaded to protect workers, staff &public. I I s v" POST-TEST PROCEDURES (Checky ram Item completed or ma - if not applicable) 1. Remove all "Lockout/Tagout" devices and nozzle bai: 2. Run all pumps and verify there are no leaks: iripact Valve Test Ports under dispensers Leak Detector Threads on STP's ❑ Functional Elements & Relief Screws 3. Install lead wire seal on all test plugs & leak detectors that were serviced. / Count LD threads: L1 _ L2 _ L3 _ L4 L5 _ L6 I G sensors, & caps 4. i Check following components operational: }d�A probes, floats, dry breaks & caps ❑ Cathodic protection operational .5aII /�Gontainment sumps are dry ❑ Di risers & POS operational f Dispenser panels are replacedJXDp tubes, flapper valves, fill adapters &caps beak detectors & vent tubes A Wpkole covers and sump lids /Monitoring system is operational ear valves are open Siphon lines and manifold valves open Spill containers & drain valves STP fittings and bayonet connectors ❑ Vents & Extractors (not capped, plugged or isolated) 5. Remove barricades. SIGN OUT & Operator Verification of Work (OVF) Lead Technician Name �� Lead Technician Signature General Safety Checks: Work area has been left clean & safe. / I 'l f Site staff aware of work status including any remaining isolation. Changes to equipment are documented and communicated. Site Representative Name Site RepresentWtive Signature All incidents, near incidents, and unsafe situations reported. Site Representative Comments: �— COMPANY CONFIDENTIAL © Tanknology Inc., 2019. All Rights Reserved. rinted copies of this document are uncontrolled. The current version is available in the Tanknoloa On-line Document Control S stem. Ovf