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W.O.# NW1-2348554 Tanknology Inc. 11000 N.MoPac Expressway.Suite'300 Austin.TX 78759 (800)964-0010 Policy 100-29-A JOB CLEARANCE FORM&SITE SAFETY CHECKLIST—OVF Rev:G Rpvised:2/11/2019 Site Name/x: Street Address: W.O.^" 7-11 1707 1� tJ. aux i ,4 �s Arrival Time: Departure Time: Travel Time: hers on site: Date ILO Scope of Work and Tasks Performed(JSA's must be available for all tasks): W 6 Repairs to Equipment or Parts Provided: , Follow-up actions required;equipment isolated;comments: q PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check.*'items used or mark-if nota licab/e Safety Vest Safety Glasses Gloves J Hearing Protection 1� Steel Toe Boots r' Splash Goggles ❑ Hard Hat ❑ Other ✓ PRE-TEST PROCEDURES Check , each item completed or mark - if notapplicable) 1. Discuss safety procedures with site personnel. Nearest hospital: vG Z ?49 /N-mC.Q 2. Prior to fuel deliveries the UST system must be placed back into working order. 3. 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. 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 w/o risk of falling in 6. ❑ Implement Lockout/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 Sig(lature General Safety Checks: All site personnel have been informed. Is a fuel delivery due today? Site Representative Name a presentative Signature LOTO procedures have been discussed. /,41Z"Vf Work areas barricaded to protect workers,staff&public. ✓ POST-TEST PROCEDURES(Check✓each item completed or mar - if not applicable) 1. - Remove all"Lockout/Tagout"devices and nozzle bags/ties. 2. Run all pumps and verify there are no leaks: - Impact 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 4. g(Check following components operational: - ATG probes,sensors,&caps - Ball floats,dry breaks&caps Cathodic protection operational AC Containment sumps are dry - Dispensers&POS operational - Dispenser panels are replaced p(Drop tubes,flapper valves,fill adapters Widaps - Leak detectors&vent tubes ,'Manhole covers and sump lids 'Monitoring system is operational - Shear valves are open LL - Siphon lines and manifold valves open QGSpill containers&drain valves t - STP fittings and bayonet connectors - Vents&Extractors(not capped,pluggeipor isolated) 5.X Remove barricades. SIGN OUT&Operator Verification of Work(OVF) Lead Technician Name S�aci Technician Signature J General Safety Checks: Work area has been left clean&safe. 6 L1 B7xS Site staff aware of work status including any remaining isolation. Site Representative Name to Representative azure Changes to equipment are documented and communicated. All incidents,near incidents,and unsafe situations reported. JCG Site Representative Comments: COMPANY CONFIDENTIAL ©Tanknology Inc.,2019.All Rights Reserved. rimed copies of this document are uncontrolled. The current version is available in the Tanknology On-Line Document Control S stem. I