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W.O.# AST -670044 Tanknology Inc. 11000N. MoPac Exprr_ssway, Suite 500 Austin, TX 78759 (800) 964-0010 Policy 100-29-A JOB CLEARANCE FORM & Rev: D° Revised: 1/24/2014 SITE SAFETY CHECKLIST — OVF Sit Name1#: Sit Street Address: W.O. Nwd- U7oq �, �u,,� u7oo&(7 Am a Time: Departure Time: Travel Time: Others on si Date 9" IU t1'k /) 2 - ( 1 Scop of Work and Tasks P rfomted (JSA's must be available for all tasks): Scop 'f n,7 s � Repairs to Equipment r Parts Provided: Follow-up actions required, equipment isolated, comments: PPE - PERSONAL MTECTTVE EQUIPMENT REQUIR Check items used or mark - if not a !!cable Safety Vest Safety Glasses XX Gbves 1 L Hearing Protection Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat F1 Other ✓ PRE-TEST PROCEDURES (Check each item completed or mark — ff not applicable) 1. ❑ Discuss safety procedures with site personnel. Nearest hospital: 2. ❑ Prior to fuel deliveries the UST system must be placed back into working order. 3. ❑ Secure entire work area with barricades (cones, flags, and caution tape, pennant flags, or other perimeter guard). 4. ❑ Place fire extinguishers and "No Smoking' signs in the work area. 5. 'D 'Implement LockoutfTagout per API 1646 (when accessing product piping during tasks) ❑ 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. —' Verify LOTO is complete by trying rate pumps. ❑ Close ball valves or check valves on product piping. ❑ Discon ct electrical "bayonet nn or from the STP(s). Le nc Na echni an ignalure General Safety Checks: i✓ All site personnel have been informed. U �1 Fuel delivery has been informed. S 6e ey mental ve eme rat ve Signa ure Is a fuel delivery due today? LOTO procedures have been discussed and agreed. A Al S s Work areas barricaded to protect workers, staff & public. POST-TEST POST-TEST PROCEDURES(Check each Item completed or mark ^ if not applicable)each item completed or mark - if not applicable) _✓ 1. ❑ Remove all "LockoutfTagout" devices. 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. C Install lead wire seal on all test plugs & leak detectors that were serviced - Count LD threads: L1 L2_ L3_ L4_ 1-5 L6 4. ❑ Check following components operational: ❑ ATG probes, sensors, & caps ❑ Ball floats, dry breaks & caps ❑ Cathodic protection operational ❑ Containment sumps are dry ❑ Dispensers & POS operational ❑ 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, pluggisolated) 5. ❑ Remove barricades. ech 'an c ead ec n.dan Signature General Safety Checks: Work area has been left tidy & safe. FZR,-. ne a to ive signature Site staff are aware of work status including any remaining isolation. ntative N Changes to equipment are documented and communicated.All incidents, near incidents, and unsafe situations reported. Stte Representative Comments: COMPANY CONFIDENTIAL ® Tanlmology Inc., 2011. All Rights Reserved. Tinted copies of dtis document are uncontrolled. 'px current version is available in the Tanknol On -Line I)oetrraart Control S m