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W . O . # NW1 - 2338552 f Tanknology Inc. 11000 N. MoPac Expressway, Suite 500 Austin , TX 78759 (800) 964w0010 Policy 100-29-A JOB CLEARANCE FORM & Rev: F SITE SAFETY CHECKLIST — OVF Revised: 3/05/2018 Site Namet#: Street Address: L19w.o. # — ( 32. 196 Z379Lt Arrival Time. [�,17u,eTi,ne: Travel Time: Ot ersonsite: Dale ) t) lct-ll'7rY Scope of work and Tasks Performed (JSA's must be available for all tasks): 14 v CArre / Repairs to Equipment or Parts Provided: f rr r �'I � a SGrcr,� r 1 oo YViq 99 f0. r td -�-o A( Fol oei- p actions required; equipment isolated; comments: rw Q V K ,w PPE - PERSONAL PROTECTIVE EQUIP ENT REQUIRED (Check ✓items used or mark ~ if notapplicable) L Safety Vest Lei Safety Glasses )r� Gloves ❑ Hearing Protection Steel Toe Boots ❑ Splash Goggles I ❑ Hard Hat ❑ Other ✓ PRE- TEST PROCEDURES (Check ✓ each item completed or mark if not applicable) 1 . Discuss safety procedures with site personnel. Nearest hospital : 2. ft�V Prior to fuel deliveries the UST system must be placed back into working order. 3. +C Secure entire work area with barricades (cones, flags, and extension bars, caution tape, pennant flags ; or other perimeter guard). 4. Place fire extinguishers and "No Smoking" signs in the work area . 5. ❑ Implement Lockoul/Tagout 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 : All site personnel have been informed, Fuel delivery has been informed. Site Representative Name Site Rep e5enlative Signature Is a fuel delivery due today? 1 _ LOTO procedures have been discussed and agreed. �� p } (n ✓ \ b Ll S{cttuq A r Work areas barricaded to protect workers, staff & public. I have discussed job clearance form ith technician. ✓ POST- TEST PROCEDURES (Check ✓ each item completed or mark if not applicable) 1 . ❑ Remove all "LockoutlTagout" devices . 2 . ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers [7 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 _ 4 . LlCheck following components operational : ❑ ATG probes, sensors , & caps ❑ Ball floats , dry breaks & caps ❑ Cathodic protection operational ❑ Containment sumps are dry ❑ Dispensers & POS operational ❑ Dispenser panels are replaced is Drop tubes, fill adapters & caps ❑ Leak detectors & vent tubes ❑ Manhole covers and sump lids Ly Monitoring system is operational ❑ Shear valves are open D Siphon lines and manifold valves ❑ Spill containers & drain valves STP fittings and bayonet connectors ❑ Vents (not capped , plugged or isolated) 5. Remove barricades . SIGN OUT & Operator Verification of Work (OVF) Lead Technician Name Lead Technician Signature General Safety Checks: l Work area has been left tidy & safe. /� c/ Site staff are aware of work status including any remaining isolation. Site R press la ive Name ite Repr entalive Signature Changes to equipment are documented and communicated. l� y All incidents, near incidents, and unsafe situations reported. S pLl r~ C'1AS �Cl Site Representative Comments: t COMPANY CONFIDENTIAL © Tanlcnology Inc., 2018. All Rights Reserved. rinted copies of this document are uncontrolled. The current version is available in the Tanknolo On-Line Document Control System.