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W.O.# NW1-2328924 <br /> Tanknology Inc. Policy 100-29-A <br /> { 1f1000MoPac Expressway,Suite i00 Austin,TX78759 (800)9640010 Rev:D <br /> JOB CLEARANCE FORM& Revised:124/2014 <br /> E SAFETY CHECKLIST—OVF <br /> Sstreet Address: <br /> .site Name/#: ��p S. hyR'r"r�•G� ��• ����!�� <br /> Arrival Time: Depai Him Time: Travel Time: I Others o site: Date <br /> Tl 5:� �� ^/,I /I- <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): <br /> Repairs to Equipment/or Parts Provided: 7 ,t <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROT IVE EQUIPMENT REQUI IRED ck items used or mark-ff nota Ifcable <br /> ety Vest ❑ Safety Glasses �' Gloves ❑ Hearing Protection <br /> Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other <br /> ./ PRE-TEST PROCEDURES!Check each item completed or mark Nnot applicawal <br /> Iiscuss safety procedures with site personnel. Nearest hospital: ;P//2. I�'Pnor to fuel deliveries the UST system must be placed back into working order. <br /> 3. Ll,Secure entire work area with barricades(cones,flags,and caution tape,pennant flags,or other perimeter guard). <br /> 4. ,G Pce 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). ❑ 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. ❑ Disconnect electrical"bayonet"connector from the STP s. <br /> SIGN IN - _ eaa Tecnmcian Name ead Te n c an sign <br /> General Safety Checks: <br /> All site personnel have been informed. Spp (aChf) t.i <br /> Fuel delivery has been informed. Site RepresenWtive Name sl epr Ive s'rat <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. J Q.JS I ,� ,Qf �� <br /> Work areas barricaded to protect workers,staff&public. I have discussed'ob d rice form with technician. <br /> ✓ POST-TEST PROCEDURES(Check each item completed or mark^ if nat applicable) <br /> 1. ❑ Remove all"LockoutITagout"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 ❑ 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: ❑ 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 0 Drop tubes,fill adapters&caps <br /> ❑ Leak detectors&vent tubes ❑ Manhole covers and sump lids <br /> ❑ Monitoring system is operational ❑ Shear valves are open <br /> ❑ Siphon lines and manifold valves ❑ Siphon lines and manifold valves <br /> L STP fittings and bayonet connectors ❑ Vents(not rapped,plugged or isolated) <br /> 5. ❑ Remove barricades. <br /> ..SIGN OUT&O retiir Vertfieatim ofWark - tea d,mdan Name T dam sly <br /> General Safety Checks: <br /> Work area has been left tidy&safe. <br /> Site staff are aware of work status including any remaining isolation. sae a entO Nam. tore <br /> Changes to equipment are documented and communicated. <br /> All Incidents,near Incidents,and unsafe situations reported. <br /> Site Representative omments: <br /> COMPANY CONFIDENTIAL 8 Tadmology Inc.,2011.All Rights Reserved. <br /> "coed copies of fts document are uncontrolled.The current ve vailable in the Tanknolo Ort-Linc Dowment Control S stem. <br /> Ovf <br />