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W.O.# NW1-2359397 Tanknology Inc. Policy IM29-A 11000 N. MoPac Expressway, Suite 500 Austin. TX 78759 1800) %4-001(, Jl -41 JOB CLEARANCE FORM &SITE SAFETY CHECKLIST - OVF Re" ° , Ir -019 Revised: Site Names � 32� � � /�j#1/^Yf,StreetLet� Acidn±sa: fig O 1.IJIMlLN W.U. . J . r '] Amval ime: eparture i rave ime:rrA hers on site ate Scope of Work and TasksP (J(JSA s must be evadable for all tasks) Repairs to Fquilprnao jr Parts Provided, Follow-up actions required, equipmerd isolated; comments: PPE - PERSONAL PRO TE VE EQUIPMENT REQUIRE heck items used or mark - if nota licable) Vest ,/steel Safety Glasses _ Gloves _ Hearing Protection ,;afety Toe Boots ❑ Splash Goggles 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. ❑ 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'bayonef connector from the STP(s). ❑ All applicable equipment disabled during test(s). ❑ Verify I - TO is complete by bAg to operate pumps. SIGN IN ician ae A ----tead Tec m Lead Techrvaan SignatureGeneral Safety Checks: All site personnel have been informed. Is a fuel delivery due today? Site RepresrR5ve Name Sde Represertative Signature LOTO procedures have been discussed. Work areas barricaded to protect workers, staff & public. ✓ POST-TEST PROCEDURES (Check ,each item completed or mark - if not aaplicablel 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. Check 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 Drop tubes, flapper valves, fill adapters & caps Leak detectors & vent tubes Manhole covers and sump lids Monitoring system is operational Shear 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 T ry an Na Lead Tacri—an Signature General Safety Checks: Work area has been left clean & safe. Site staff aware of work status including any remaining isolation. ite Representative Name Site Representative Signature Changes to equipment are documented and communicated. All incidents, near incidents, and unsafe situations reported. rte epresentative Comments: COMPANY CONFIDENTIAL O Tanknology Inc., 2019. All Rights Reserved. k1r'nted copies of this document are uncontrolled. The curtent version is available in the Tanknolo On -Line Document Control SiiiE