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0 <br /> Tanknology Inc. <br /> 11000 N.MoPac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Policy 100-29-A D <br /> j JOB CLEARANCE FORM& Rev:Revise <br /> (n <br /> d:l/24/2014 � <br /> SITE SAFETY CHECKLIST-OVF rn <br /> V <br /> Site Name/#: Street Address: W.O.# � <br /> s zv r12-14r- /3Z-" <br /> 6,/, OF r12,% 95'37 6-70 -307 CD <br /> Arrival ime: parture Time: Travel Tim Others on site: Date W <br /> W <br /> 7' .y5r //-0/- <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): <br /> Repairs to Equipment or Parts Provi ed: <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark-if notapplicable) <br /> Safety Vest afety Glasses B'Gloves ❑ Hearing Protection <br /> .❑/Steel To <br /> Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other <br /> ✓ PRE-TEST PROCEDURES(Check each item completed or mark-if not applicable) <br /> 1. ❑ Discuss safety procedures with site personnel. Nearest hospital: <br /> 2. ❑ Prior to fuel deliveries the UST system must be placed back into working order. <br /> 3. ❑ Secure entire work area with barricades(cones,flags,and caution tape,pennant flags,or other perimeter guard). <br /> 4. ❑ Place fire extinguishers and"No Smoking"signs in the work area. <br /> 5. ❑ Implement Lockout/Tagout per API 1646(when accessing product piping during tasks) <br /> ❑ All applicable equipment disabled during test(s). ❑ Secure the circuit breaker(s)with lockout devices and tags. <br /> ❑ Secure nozzles with"Out of Service"bags and nylon ties. ❑ Verify LOTO is complete by trying to operate pumps. <br /> ❑ Close ball valves or check valves on product piping. ❑ Disconnect electrical"bayonet"connector from the STP(s). <br /> SIGN IN Lead Technician Name chmcian Signature <br /> General Safety Checks: <br /> All site personnel have been informed. P4, r <br /> Fuel delivery has been informed. <br /> te n presenta <br /> Is a fuel delivery due today? iu ame Site a nta gn re <br /> LOTO procedures have been discussed and agreed. Q/}VY ;jdh h <br /> Work areas barricaded to protect workers,staff&public. I have discussed job clearance form with technician. <br /> ✓ POST-TEST PROCEDURES(Check each item completed or mark-if not applicable) <br /> 1. ❑ Remove all"LockoutlTagout"devices. <br /> 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers <br /> ❑ Leak Detector Threads on STP's ❑ Functional Elements&Relief Screws <br /> 3. ❑ Install lead wire seal on all test plugs&leak detectors that were serviced. <br /> Count LD threads: L1 L2 L3 L4_ L5_ L6_ <br /> 4. 0 Check following components operational: ❑ ATG probes,sensors,&caps <br /> ❑ Ball floats,dry breaks&caps ❑ Cathodic protection operational <br /> ❑ Containment sumps are dry ❑ Dispensers&POS operational <br /> ❑ Dispenser panels are replaced ❑ Drop tubes,fill adapters&caps <br /> ❑ Leak detectors&vent tubes ❑ Manhole covers and sump lids <br /> ❑ Monitoring system is operational ❑ Shear valves are open <br /> ❑ Siphon lines and manifold valves ❑ Siphon lines and manifold valves <br /> ❑ STP fittings and bayonet connectors ❑ Vents(not capped,plugged or isolated) <br /> 5. ❑ Remove barricades. n <br /> Lead Technician Name Le T hnician ature C <br /> SIGN OUT 8 Operator Verification of Work OVP in <br /> General Safety Checks: r* <br /> Work area has been left tidy&safe. Ila <br /> - <br /> Site staff are aware of work status including any remaining isolation. Sae presentahv Namea ve signature CD <br /> Changes to equipment are documented and communicated. # <br /> All incidents,near incidents,and unsafe situations reported. Pe AN// AFJOvJI5 <br /> Site Representative Comments: <br /> O <br /> W <br /> 00 <br /> COMPANY CONFIDENTIAL ©Tanknology Inc.,2011.All Rights Reserved. <br /> rented co ies ofthis document aze uncontrolled.The current version is available in the Tanknology On-Line Document Control System. W <br />