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W.O.# AST-6702581 <br /> Tanknology Inc. <br /> 11000 N.MoPac Ilxpres—ay,Suite 500 Austin,TX 79759 (800)964-0010 Policy 1U0-29-A <br /> JOB CLEARANCE FORM& R` <br /> Revised;1/24/2014 <br /> SITE SAFETY CHECKLIST—OVF <br /> Site Namerd Street Address: W,O.# <br /> y7 j /=i T� CT <br /> Yl a l - tl5i 7726-2, <br /> C/ 5 — v <br /> Arrival Time: Departure Time Travel Time: Others on site: Dale <br /> (2y 1 io ,�): - <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): <br /> T 7 <br /> Repairs to Equipme or Parts rovided: <br /> Follow-up actions required,equipment isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark—if notapplicable) <br /> Safety Vest 1---66fety Glasses 'I✓,Gloves Hearing Protection <br /> _L—Steel Toe Boots Splash Goggles Hard Hat Other <br /> ✓ PRE-TEST PROCEDURES (Check each item completed or mark if not applicable) <br /> 1. V_—�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. G' 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). 1 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. _i Disconnect electrical"bayonet"connector from the STP(s). <br /> SIGN IN Lead Technician Name ea Te hnician Signature, <br /> General Safety Checks: <br /> All site personnel have been informed. Fr b <br /> Fuel delivery has been informed. ae epresen live Name e e se r ig wr <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. . <br /> Work areas barricaded to protect workers,staff&public. I have discussed job cl a form with tee nician. <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 C 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: I I ATG probes,sensors,&caps <br /> Ball floats,dry breaks&caps Ll 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 C Shear valves are open <br /> Siphon lines and manifold valves LI Siphon lines and manifold valves <br /> _ STP fittings and bayonet connectors Ll Vents(not capped,plugged or isolated) <br /> 5. Remove barricades. <br /> SIGN OUT&Operator Verification of Work OVF Lead Technician Name �echnicianlure <br /> General Safety Checks: <br /> Work area has been left tidy&safe. Jt <br /> Site staff are aware of work status including any remaining isolation. i e epres orale a Si n 've Signature <br /> Changes to equipment are documented and communicated. /J <br /> S. <br /> All incidents,near incidents,and unsafe situations reported. L/ - r <br /> Site epreaentalive Comments: <br /> COMPANY CONFIDEN'rIAL c),ranknoloL,v Inc.,2011.All Rights Reserved. <br /> Tinted copies of this document are uncontrolled. The current version Is available in the TanknoloEy On-Linc Document Control Svstem <br />