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, Po ianknology SITE SAFETY CHECKLIST, SERVICE AGREEMENT & OPERATOR VERIFICATION FORM Site Nime: Address: ✓ POST-TEST PROCEDURES W.O. ❑ Discuss safety procedures with site personnel. 1. ❑ Remove all "Lockoul/Tagout" devices. 2. ❑ Prior to fuel deliveries, the complete tank system 2. ❑ Run all pumps and verify there are no leaks under dispensers or Site N: City/ST/Zip: 3. Date: ❑ Impact Valve Test Port the product(s) to be tested must be disabled during ❑ Leak Detector Threads the test(s). Scope of Work: 4. ❑ Secure entire work area with 28" cones, flags, and 3. ❑ Install a lead wire seal on all test plugs & leak detectors that caution tape. were serviced. Count LD threads: 5. ❑ Place fire extinguishers and "No Smoking" signs in L1 -_L2 L3 L4 L5 Parts & Materials Provided: the work area. _ _ _ _ 4. ❑ Ensure that all tank system components are restored to their 9. Arrival Time at Site: / , '/ S original state (including): Departure Time from Site: l '— ov l Total Travel Time: ATG probes, sensors, & caps Signature below confirms that the items listed in the POST-TEST Procedures hdJe been visually verified by the location representative. Pre -Test Signature I Post -Test Signature ✓ PRE-TEST PROCEDURES ✓ POST-TEST PROCEDURES 1. ❑ Discuss safety procedures with site personnel. 1. ❑ Remove all "Lockoul/Tagout" devices. 2. ❑ Prior to fuel deliveries, the complete tank system 2. ❑ Run all pumps and verify there are no leaks under dispensers or must be placed back into working order. in STP sumps. Must be witnessed by site representative. 3. ❑ All pumps, dispensers, and electrical breakers of ❑ Impact Valve Test Port the product(s) to be tested must be disabled during ❑ Leak Detector Threads the test(s). ❑ Functional Element & Relief Screw 4. ❑ Secure entire work area with 28" cones, flags, and 3. ❑ Install a lead wire seal on all test plugs & leak detectors that caution tape. were serviced. Count LD threads: 5. ❑ Place fire extinguishers and "No Smoking" signs in L1 -_L2 L3 L4 L5 the work area. _ _ _ _ 4. ❑ Ensure that all tank system components are restored to their 9. ❑ Turn off and secure the circuit breaker(s) of the original state (including): product to be tested with lockout devices and tags. ATG probes, sensors, & caps 7. ❑ Place "Out of Service" bags on the dispenser nozzles Ball floats, dry breaks & caps of the product(s) to be tested. Cathodic protection system is operational 8. ❑ Verify proper Lockout/Tagout procedure is complete Containment sumps are dry by trying to operate pumps. Dispensers & POS system 9. ❑ Close ball valves or check valves on the product Dispenser panels are replaced piping to be tested. Drop tubes, fill adapters & caps 10. ❑ Remove the electrical "bayonet" connector from - Leak detectors & copper vent tubes 1 V the STP(s). - Manhole covers and sump lids Monitoring system is operational I _Shear valves at the dispensers Siphon lines and manifold valves aj✓ - Spill containers & drain valves - STP fittings and bayonet connectors 5. ❑ Remove cones, flags, and caution tape. l Tanknology - Pre -Test Signature - Post -Test Signature Signature below confirms that the items listed in the POST-TEST Procedures hdJe been visually verified by the location representative. Pre -Test Signature I Post -Test Signature