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TanknOlogy Inc• Policy 1.00-29-A <br /> F 11000 N.MoPac&Press'aY%Suite 500 Austin, LAX 78759 (860)964-0010 Rev:]7 <br /> JOB CLEARANCE FORM'& Revised: 1/24/2014 <br /> SITE SAFETY CHECKLIST—OVF <br /> ` W.O.# <br /> Street Address_ <br /> Site Namel#: Date <br /> el Ti Oow!§"on it <br /> An iva'Time: Departure Time: <br /> Scope of Work and Tasks Performed(JSA's must be available for an7asksY <br /> Repairs to Equipment or Parts Provided <br /> low-up ctio / required;equipment isofated;commer�is " <br /> ' _ <br /> le <br /> EQUlpMENT REQt�t eck litems tsed'or mark ifirlH rcabte <br /> PPE-pERSONAL PRO Gloves ❑ Hearing Protection <br /> S Vest _ afeiy Glasses ❑ <br /> Hard HatOther <br /> ❑. Splash Gaggles U . :. <br /> steel Toe Boots Ilowd or mark if not Iicable <br /> �/ PRE-TEST PROCEDURES'^ each item <br /> Discuss safety procedures with site personnel. Nearest hospital: <br /> 1. <br /> 2. ❑ Prior to fuel deliveries the UST systerrr�ust_blaced track into working oirder.nt flags,or other perimeter guard). <br /> 3_ ecure entire work area with bamcades(cones,flags.and caution tape.Penna <br /> 4 dace fire extinguishers and"No Smoking"signs in t owiork area. <br /> product piping during tasks) <br /> 6, ❑ Implement LockoutfTagout per API 1646(when accessing <br /> Sere the breaker(s)with lockout devtees.and tags. <br /> All applicablet drsab during test(s). b trying to ate pumps. <br /> bagsand rryton fA ;-Q Verify LOTO is complete Y <br /> .�urenozziesrah9e[at _ o from theSTP(s). ' <br /> 0' isW1s11eQeittchical-barneC <br /> Close ball v'atves otrtvst7n produ#P Lead Signatu� <br /> Lead <br /> General Safety Che s <br /> All site personnel have been informed= Re Signature <br /> f e Rep .. <br /> Asa ery due today? _ <br /> •QTO proci:dures have been discussedandagreed b oleardtic�onrr <br /> VYork:areas barricaded to protect worker's,s�& _ _. <br /> _ - mark ^' MAW ble <br /> ./ POST TEST each ifem,rare <br /> 1_ — Remove al%0dwdYJTagNrdVAXS- — bmpad Valve Test Ports under dispensers <br /> ` al pmlps aad aim t Funcponat Elements&Relief Screws <br /> 3_ Ins lea ors�weaesaviced <br /> Count L©threads L1 3.,;­:- L4. <br /> 4 Check following components perabonal. Ej ATG pmb3s,sensors,&✓caps <br /> _ ❑ <br /> pBa I floats,dryl <br /> 0 Cptptection operational <br /> _ n#aipment sumT <br /> aei ee®ers POS operational 7 <br /> dapters&caps <br /> ae <br /> Nilpenser panefsrlti6Ced a <br /> ❑ Leak detectors W4L awbes <br /> ❑ Manhole cdisand sump lids <br /> ❑ Monitoring system ❑ Shear ,- open <br /> fines and mandold,aratves <br /> ❑ Siphon lines and 0 <br /> STP�al�ayonet connectors ❑ Verds(nof`capped,Plugged orI ted) <br /> 5. - . <br /> Lead Techn 'an me` e Technician Signature <br /> General Safe -Checks: <br /> tlR a,_ =' <br /> Work area has�heen left tidy safe. 1slive gnure <br /> Site staff are aware ofwasksta6is including any rerrtarlrt9 nsola6SftFepFe"ntative Name <br /> Changes to equipment ati mented and comm nicabA = i <br /> VI incidents,near incidents,and unsafe sftsaWrm,tai,6101 . b ee <br /> Representative Comrneris <br /> IMPANY CONFIDlUff LAL ®Tanlmology Inc.,2011.All Rights Reserved. <br /> rinted copies of this document are uncontrolled. The current version is available in the Tanlmoto ir On-Line Document Control S stem <br /> I <br />