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RKllology Inc. Policy 140 2' A <br /> l0. �vloPac Expressway,Suite 500 Austin,TX 78759 (800)964 0010 Rev:'D <br /> j(-t3-_4 .: <br /> JOB CLEARANCE FORM & Revised:1/24/2014 <br /> ° ' 5ITEf AFET CHECKLYST-OVF <br /> .: :.: Street Addre O <br /> W. .# <br /> S - t �G <br /> dtFiets e v Date <br /> Arrival 11 - '-1'7 1'C7 <br /> L <br /> Sc ofU0, <br /> nd Tasks Performed(JSA's m st be aailableforailtasft, <br /> 5 f <br /> Repairs to Eq ipmen or P Pro01 <br /> ; <br /> Fol ow up actions required;equipment isolated court lents: h <br /> PPE-PER5QIVAL MjE EQfllPli MT REQWRE _ items used ormafrk=7fnot licable <br /> Safety Glasses - ❑ Gloves ❑ otheHear g Protection <br /> Safety Vest ❑ Outer <br /> ❑ Splash Goggles ❑ Hard-Hat: <br /> Steel T :Boots ": <br /> �afe <br /> j2DF.TEST PR�CEDUI4FSur' sled or mark"' if not a Discusty Procedures <br /> whh site Person <br /> Nearest hospital <br /> ., working <br /> 2. ❑ nor to fuel deliveries the LW system must be placed bade into ww pegpennant flags,or other.perimeter guard) <br /> 3. ure entire work area-:t AM barricades(cones.fla <br /> 4; lace fire extinguishers arid,W Smoking"signs in the.work area. tasks <br /> r ct piping during ) <br /> 5 ment Lockout7agout perAPl 1646(when�eoessur9 Sectae the circuit bmaker(s)with lockout devices and tags. <br /> licable equipment disabled�tning tests}. <br /> _ with"Out of Set bags and nylon ties. � .% -is cornp�te by trying to operate pumps. <br /> Is r efericaLnet"connector from the STP(s) X <br /> y� Close OF-dreck valve`sao•pro�uc'��tiping clan I Tedai®n si ure <br /> General <br /> Ali site pe been i resent�ue Name yresentative Signature <br /> has been informed. <br /> Is ry titre today + .. <br /> T' procedures haOW66n discussed and agreed_ <br /> -Work areas b~d to protect workers,sof&public have'` Center f4mn�vi Fite <br /> " f (POST- T each i eted or mark ~ if not a lice <br /> ! Remove alf'Eadao�lT r <br /> ` 2 Fhn ail pumps and ven7y there are no leaks: ❑ lu act Va1vgjest Ports under dispensers <br /> - Leak ds on STP's t? i=unctiona!Elements 8 Relief Screws <br /> 3. ❑ '!' wire seal on all test piugs8 ere serviced. � a <br /> Coli Ll efe �ta�ilL5 L6 <br /> 4. Check followtn _ ap�eaiional: ATG probes,sen <br /> floats,dry b gaps jll- o <br /> Yj <br /> _Containment sum <br /> ,= OS operational <br /> Dispe-pepa ced €. fill adapters&caps <br /> &vent ibes rcoversand sump I'ds t <br /> MoniForing system is.opertaE Shear valves are open " <br /> R <br /> r.•__. " Siphon lines and mani _ ❑ Siphon lines aad manifold valves y <br /> r p S�pfit6ftgs arm bayonet ca eats(nodcapped plugged a a) <br /> 5. Remove bamcades. _ - <br /> L d eche, nat8re <br />� Lead T Nam ' <br /> General Safety...Checks: - <br /> Workareahas�ieenlebtiidy&safe_ �� = t,ves�gnature. <br /> Site staff are agate of work stalls' ��Jain.m isof'ation. iia Rearesen = <br /> Changes to eqt pmerrt are docirnerrl�erlicaw—.1 <br /> reported. <br /> t�tiatians - O <br /> and <br /> All incidents near <br /> site RepresenFue connnr"ils: <br /> ¢ COMPANY C{)NfFIDEhT!ICPii} = 0 Tanknology Inc.,201 L Ali Rim Reserved. <br /> Printed 'es of this docunnmt are t oa&iolled. The current version is" le in the Tattlmolo On-Line Document Control <br />