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Tanknology Inc. POD`" t <br /> 11000 N.MoPac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Rey'=H <br /> JOB CLEARANCE FORM& SITE SAFETY CHECKLIST <br /> ;a, I <br /> Site N meh': Street Address: W 4`' Q <br /> tvx•� q'�{��,5 p5 6..Q t N <br /> Arrival Time. Geplafise Time: Travel Time: Others on site: Date <br /> t :C30 5-1 s p 1 <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): <br /> /n/ prJ <br /> Repairs to Equipment or Parts P vided: <br /> Z61",oV60 Zr v d ue¢y19 Rti ILA S PS <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check "items used or mark—if not a piicable <br /> Safety Vest/Shirt(all jobs) � Gloves(all jobs) Splash Goggles(if needed) _ Hearing Protection(if needed) <br /> Safety Toe Boots(all jobs) Safety Glasses(all jobs) Hard Hat(if needed) Other <br /> ✓ PRE-TEST PROCEDURES Check ✓each item completed or mark -- if notle&Lcablel <br /> 1. Discuss safety procedures with site personnel. Nearest hospital: v <br /> 2. Get ATG printout&check fuel/water levels. Prior to fuel delivery the system must be placed back into working order. <br /> 3. Barricade work area(cones,flags, bars/tape)and place Fire Extinguishers&"No Smoking"Signs at perimeter. <br /> 4. 1 Confined Space Entry—If required complete separate CSE Checklist. If NO CSE check the following reason: <br /> []No CS's _CS's not opened _No entry only visual *o entry-used tools CWork from prone position w/o risk of falling in <br /> 5. ❑ Implement Lockout/Tagout per API 1646(when accessing product piping during tasks) <br /> ❑ Secure nozzles with"Out of Service"bags and nylon ties. _ Secure the circuit breaker(s)with lockout devices and tags. <br /> ❑ Close ball valves or check valves on product piping. _ Disconnect electrical"bayonet"connector from the STP(s). <br /> All applicable equipment disabled during test(s). _ Verify LOTO is complete by trying to operate pumps. <br /> SIGN IN Lead Technician Name Lead TechN 'an Signature <br /> General Safety Checks: / <br /> All site personnel have been informed. <br /> Is a fuel delivery due today? (/ <br /> LOTO procedures have been discussed. Site Representative Name/1 p Representative Signature <br /> Work areas barricaded to protect workers,staff&public. <br /> ✓ POST-TEST PROCEDURES (Check ✓each iten completed or r;lii,lr,1l1, if n�ta-pplicabh1le)) <br /> 1. Remove all'Lockout/Tagouf devices and nozzle bags/ties. <br /> 2. Run all pumps and verify there are no leaks: Impact Valve Test Ports under dispensers <br /> Leak Detector&Vent Tubes STP Functional Elements& Relief Screws <br /> 3. Get ATG printout. Confirm water levels same as start or explain difference: <br /> 4. OlCheck following components operational: <br /> ATG probes,sensors,&caps _ Shear valves are open <br /> Ball floats,dry breaks&caps _ Dispensers&POS operational <br /> of Containment sumps are dry = Dispenser panels are replaced <br /> ,IrManhole covers and sump lids = Vents&Extractors(not capped, plugged or isolated) <br /> Spill containers&drain valves - Cathodic protection operational <br /> Drop tubes, flapper valves,fill adapters&caps = Siphon lines and manifold valves open <br /> 5. Gv Remove barricades. <br /> SIGN OUT&Operator Verification of Work(OVF) Lead Technician Name <br /> General Safety Checks: 11 ad T ch dan re <br /> Work area has been left clean&safe. ` � "�. <br /> Site staff aware of work status including any remaining isolation. <br /> Changes to equipment are documented and communicated. Site Representative Name a epresentative Signature <br /> All incidents,near incidents,and unsafe situations reported. '(, L / <br /> Site Representative Comments. 1 V 1 <br /> COMPANY CO. FIDENTIAL <br /> 0 Tanknolo Inc..2022.All Rights Reserved. <br /> Prin[ed copies of this document are uncontrolled. The current.ersion is available in the Tanknolo On-Line Document Control Svstem <br />