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Tanknology Inc. O <br /> I10(W N MoPac Espresswag,Suite 500 Austin,TX 78759 (800)%4-0010 Policy 100.29-A <br /> JOB CLEARANCE FORM& Rev.D D <br /> LA�� Revise 12412014 <br /> SITE SAFETY CHECKLIST-OVF <br /> Site Name/N <br /> Street Address W O.# <br /> /719,o rn A)Ll0Psi3 00 V <br /> J I <br /> 0 <br /> T - r Z< _ fV <br /> Arrival Time: parture Time. Trava tme. Others on site: Dste W <br /> Scope of Work and Tasks Perfonmed(J A's must be available for all tasks) <br /> Repelrs to Fitulpment or Parts Provided <br /> Follow-up actions required.equipment isolated.comments: <br /> PPE-PERSONAL PRO TIVE EQUIPMENT REQUIRED Check items used or mark-N notapplicable) <br /> Safety Vast Safety Glasses Gloves Hearing Protection <br /> Sleet Tae Boots Splash Goggles Hard Hal Other _ <br /> ✓ PRE-TEST PROCEDURES(Check each Nem completed or mark—N not applicable) <br /> 1. Discuss safety procedures with site personnel. Nearest hospital. <br /> 2. .i 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 LockoutlTagout per API 1646(when accessing product piping during tasks) <br /> All applicable equipment disabled during testis). Secure the circuit breaker(a)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 of check valves on product piping. Disconnect electncal'bayonat-c9anclour from the STP(s). <br /> SIGN IN t.aa .chr,oan N.— <br /> All <br /> a/ <br /> General Safety l Chocks:b: '+ <br /> All site personnel have been informed. r <br /> Fuel delivery has been informed. to epresentam. erne . . nm,ve s pence <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 clearance form with technician. <br /> ✓ POST-TEST PROCEDURES(Check each)tem completed or mark—If not applicable) <br /> 1. ', Remove all'Lockoutfragout"devices. <br /> 2. Run all pumps and verify there are no leaksImpact 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 LS_ L6 <br /> 4. ❑ Check following Components operational I 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 /> CJ Monitoring system is operational Shear valves are open <br /> ❑ Siphon lines and manifold valves ! Siphon lines and manifold valves <br /> C STP fittings and bayonet connectors Vents(not capped,plugged or isolated) <br /> 5. U Remove barricades. <br /> nipan .n,e ec,r�cwn <br /> a ovF .i <br /> vmk wee los been lett imy a safe. <br /> an shelf are awes of work status ktrJAng any remaining isolation esen...... ane ria l:eprosentatrve spnawr� <br /> Cf WqW 1p eoltrfprnsrp era documain;ed and communicated. <br /> N kXj*rlls,roar ktcYlarNs,and unsafe situations reported. <br /> -W,IwPollailip" <br /> 1kD14 COf1R1D0111*117L46 _1:,nLmdet;.1,%.2011.All Rights Rc—d. <br /> �eirad aadM dWs d lilaeAs are tarcarNolled rbe current version is availnblc in ih I v k ,I rev On-bine D x umcnt Control Svstem <br />