Laserfiche WebLink
W.O.# NW1-2328941 <br /> Tanknology Inc. <br /> t 1000 N.Mupac Expressway,Suite 500 Austin,TK 797591 (900)964-0010 Policy]OQ-29-A <br /> JOB CLEARANCE FORM & Rev:D <br /> Revised:1)24/2014 <br /> SITE SAFETY CHECKLIST-OVF <br /> �Site name/#; Street Address: W.O.# <br /> Arrival Time: Departure Time: Travel Time: Others on site: Date <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks) <br /> Repairs to Equipment or Parts Provided: <br /> rh <br /> 1, <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROT CTWE EQUIPMENT REQUIRED Check ifems used or mark-if nota licab)e) <br /> Safety Vest ety Glasses doves Hearing Protection <br /> „Steel Toe Boots Splash Goggles Hard Hat Other <br /> PRE-TEST PROCEDURES Check each Item completed or mark if not a licable <br /> f. V Discuss safety procedures with site personnel. Nearest hospital: <br /> 2, t/�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 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"bay one o ector f the STP(s). <br /> SIGN IN Lead Technician Name a Technic n Signature <br /> General Safety Checks: <br /> All site personnel have been informed. I t <br /> Fuel delivery has been informed. Y r i Site Reprecentative Nave oi!e Representative signature <br /> Is a fuel delivery due today? t�Z1 <br /> LOTO procedures have been discussed and agreed. <br /> Work areas barricaded to protect workers,staff&public. l have discussed job clearance form with technician. <br /> ./ POST-TEST PROCEDURES!Check each item completed or mark — if not applicable) <br /> 1. Remove all"LockoutrTagout"devices. <br /> 2. : dun 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 l-5 L6 <br /> 4, heck following components operational: i_,.A-TG 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 /> VMonitoring system is operational Shear valves are open <br /> Siphon lines and manifold valves Siphon lines and manifold valves <br /> / STP fittings and bayonet connectors Vents(not capped,plugged or isolated) <br /> 5. `'� Remove barricades. <br /> SIGN OUT&Operator Verification of Work(OVF).. Lead Technician Name L ician Signature <br /> General Safety Checks: �� r <br /> Work area has been left tidy&safe. j <br /> Site staff are aware of work status Including any remaining isolation, S*Representative Name Ste Representative Signature <br /> Changes to equipment ar9 documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. <br /> Site Representative Comments:, <br /> COMPANY CONFIDENTIAL O Tanknology lnc.,201 t,All Rights Reserved. <br /> rintcd copies of this document are uncontrolled. The current version is available in the Tanknology On-Line Document Control S stem. <br />