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W.O.# NW1-2330296 Cust Ref# : CUCO PO# 0015230347 _ Tanknology Inc. -- - 11000 N.1v1ol'ac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Policy 100-29-A JOB CLEARANCE FORM& Rev:D Revised:1/24i2014 SITE SAFETY CHECKLIST-OVF Site t- me!#: Street Address: W.O.# � gvn�J "t- 30Z70q IM c �530).g& Arrival Time: Departure Time: Travel Time: Oltlars on site Date d !8" 3d Scope of Work and Tasks Performed(JSA's must be available for all tasks): L A 5,5, S- W, o. 0 -DSD Re to Equ ent or rts Provided," f f/AG 2 d SIP /L6 !�J On/�� /i(!� C.('O T// 06 L WSt� Y SO �O�.tz�.t', f� /SA'"�j ON'rL3 5616 c,oc6o �itw t n/ p vo S!ltrt E r w .J Foll w-up actions required:equipment isolated;comments: Cb..�Pi stern PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check Items used or mark—if not applicable) 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 notapplicable) 1. Discuss safety procedures With site personnel. Nearest hospital: d! L L 2. Prior to fuel deliveries the UST system must be placed back into working order. 3. A Secure entire work area with barricades(cones,flags,and caution tape,pennant flags,or other perimeter guard). 4. Ae Place fire extinguishers and'No Smoking"signs in the work area. 5. 0( Implement Lockoutlfagout per API 1646(when accessing product piping during tasks) K All applicable equipment disabled during test(s) Secure the circuit breaker(s)with lockout devices and tags. Secure nozzles with"Out of Service"bags and nylon ties. I Verify LOTO is complete by trying to operate pumps. Close ball valves or check valves or product piping. _ Disconnect electrical'bayonet'connector from the STP(s)- SIGN IN Lead Technician Name Lead Technicisn ignatum General Safety Checks: All site personnel have been informedy��J�t6»t5 Fuel delivery has been Infdmled. SEe Representative Name de Represents a Signature -- Is a fuel delivery due today? /�` 12' L_(✓ N LOTO procedures have been disco ed and agreed. l._. Work areas barricaded to protect workers,staff&public. I have discussed'ob clearance form with technician. ✓ POST-TEST PROCEDURES!Check each item completed or mark - if not applicable) 1. Remove all"LockouttTagout"devices. ,/ 2. Run all pumps and verify there are no leaks: tl, Impact Valve Test Ports under dispensers -. Leak Detector Threads on STP's -1 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 i;< Check following components operational: f�ATG probes,sensors,&caps Ball floats,dry breaks&caps Cathodic protection operational Containment sumps are dry Dispensers&POS operational ,41 Dispenser panels are replaced Drop tubes,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 Siphon lines and manifold valves ^� STP fittings and bayonet connectors Vents(not capped,plugged or isolated) 5. (JC Remove barricades. SIGN OUT&Operator Verification of Work(OVF) in Name Lead Technician Signature General Safety Checks: Work area has been left tidy&safe. u' �/6 �t✓d Sr✓LS 11U4/i�•a' Site staff are aware of work status including any remaining isolation. -- Site Representative Name rte Re sentative Svnature Changes to equipment are documented and communicated. All incidents,near incidents,and unsafe situations reported. site Representative Comments: COMPANY CONFIDENTIAL C Tanknology Inc.,2011.All Rights Reserved. Printed copies of this document are uncontrolled.The current version is available in the 1 anknolo On-Line Document Control System a