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0 <br /> Tanknology Inc. Policy 100-29-A > <br /> 11000 N.MoPac Expressway,Suite to Austin,TX 78759 (800)964-0010 <br /> JOB CLEARANCE FORM& Rev:F W <br /> Revised:3/05/2018 <br /> SITE SAFETY CHECKLIST—OVF <br /> rn <br /> Site Namef#: Street,� O Address: 5Gh VUT� W O# W <br /> S 7-NN�� Cli ` ro7D30 1 0 <br /> AmvaIme: MY Departure Time: Travel ime: Others on site: Date <br /> F-r <br /> R�;XU = L //- -lk- <br /> atl Tasks Performed WSA's must be available for all tasks), <br /> T <br /> Repairs to Equipment or Parts Provided: <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check✓items used or mark—if not applicabM2 <br /> C' >fety Vest P"Safety Glasses 14 loves ❑ Hearing Protection <br /> Steel Toe 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 extension bars,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 /> ❑ 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 testis). ❑ Verity LOTO is complete by trying to operate pumps. <br /> SIGN IN Lead Technician Name Lead Technician Signature <br /> General Safety Checks: <br /> All site personnel have been informed. <br /> Fuel delivery has been informed. site <br /> Is a fuel delivery due today? / -epresenta ive Name to R sen ative Signature <br /> LOTO procedures have been discussed and agreed. C b'L „✓ <br /> �- <br /> Work areas barricaded to protect workers,staff&public. I have discussed'ob clea lice tortn with technician. <br /> ✓ POST-TEST PROCEDURES(Check- each item completed or mark — if not applicable) <br /> 1. ❑ Remove all"Lockout/Tagout"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. ❑ 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 ❑ Spill containers&drain valves <br /> ❑ STP fittings and bayonet connectors ❑ Vents(not capped,plugged or isolated) <br /> 5. ❑ Remove barricades. <br /> SIGN OUT&Operator Verification of Work(OVF) Lead Technician Name ad Tech ician si ture <br /> General Safety Checks: <br /> Work area has been left tidy&safe. Th e/v <br /> Site staff are aware of work status including any remaining isolation. Sit Represent five Name Si[e rese tative Signature <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. <br /> Site Representative Comments: <br /> im6k.COMPANY CONFIDENTIAL, ©Tanknology Inc.,2018.All Rights Reserved. <br /> 'n[ed copies of this document are uncontrolled The currentemmion is available m[he Tanknology On L ne Document Control Svs[em <br />