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W.O.# NW1-2361632 Tanknology Inc. 11000 N.MoPac Fxpressway,Suite 500 Austin,TX 78759 (800)964-0010 Policy 100-29-A JOB CLEARANCE FORM&SITE SAFETY CHECKLIST-OVF Rev:G Revised:2/11/2019 Site Name/#: � � � tree)Address: W.O.u Arrival ime: eparture ime: Trave T—Ime Othets on site: Date Sco f Work and ks Performed(JSA'stnust be avail for all tasksl: Repairs to Equipment or arts Provided: Follow-up actions required;equipment isolated:comments: PE-PERSONAL PROTE E EQUIPMENT REQUIRED heck✓items used or mark—if notapplicable) Safety Vest Safety Glasses Gloves ❑ Hearing Protection Steel 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. ❑ �rfor to fuel deliveries the UST system must be placed back into working order. 3. KP e entire work area with barricades(cones,flags,and extension bars,caution tape,pennant flags,or other perimeter guard). 4. e 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"conn for from the STP(s). All applicable equipment disabled during test(s). ❑ Verify LOTO is complete by tryin to operate pumps. SIGN IN Lead Tecame ad Technician Signature General Safety Checks: All site personnel have been informed. )rArrdU Is a fuel delivery due today? Site Representative ame Site Representative 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 applicable) 1. Remove all"Lockout/ragout"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. Ins II lead wire seal on all test plugs&leak detectors that were serviced. Count LD threads: Li _ L2_ L3_ L4_ L5_ L6 4. Check following components operational: ATG es,sensors,&caps Rall floats,dry breaks&caps C odic protection operational C tainment sumps are dry ispensers&POS operational /Dip enser panels are replacedCI tubes,flapper valves,fill adapters&caps k detectors&vent tubes /hole covers and sump lids //Monitoring system is operational hear 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(CIVF) Lead Technital Name Lead Technician Signature General Safety Checks: Work area has been left clean&safe. Site staff aware of work status including any remaining isolation. -Site Representative Name Site Representative Signature Changes to equipment are documented and communicated. All incidents,near incidents,and unsafe situations reported. Site RepresentativeComments: COMPANY CONFIDENTIAL ©Tanknology Inc.,2019.All Rights Reserved. Printed copies of this document are uncontrolled. The current version is available in the Tanknolo On-Line Document Control S stem.