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Tanknology Inc. <br /> 8501 N.MoPac Expressway,Suite 400 Austin,TX 78759 (800)964-0010 Policy 100-29-A <br /> i,._3 JOB CLEARANCE FORM & Rev:D <br /> Revised:8/04/2408 <br /> SITE SAFETY CHECKLIST — OVF <br /> Site Name/#: 1 Street Address: W.O.# <br /> Ar val Time: DepartureTime: Travel Time: Others din site: Date �7 <br /> , <br /> Scope of Work and Trasks Performed(JSA s must be available for all tasks): <br /> Re airs to Equipmet or Parts Provided: <br /> FoIllow-ullil actions required:equipment Isolated; mm ts: <br /> PP -P€RSONAL PPOTECTIVE EQUIPMENT R€QUIRED Check items used or mark if nota llcab!e <br /> fety Vest Safety Glasses Gloves IJ Hearing Protection <br /> 3 Steel Toe Soot ❑ Splash Goggles ❑ Hard Hat I_1 Other <br /> PRE-TEST PROCEDURES Check each item completed or mark •- if notapplicable) <br /> 1. r7­�Discuss 3afety procedures with site personnel. Nearest hospital: <br /> 2. ;`j Prior to el deliveries the UST system must be placed back into working order. <br /> 3. Secure 4ntire work area with barricades(cones,flags,and caution tape, pennant flags,or other perimeter guard). <br /> 4. �P ce firs extinguishers and"No Smoking"signs in the work area. <br /> 5. Imple e t Lockout/Tagout per API 1646(when accessing pr uct piping during tasks) <br /> II applicable equipment disabled during test(s). �S'ecure the circuit breaker(s)with lockout devices and tags. <br /> ❑ Secur3 nozzles with"Out of Service"bags and nylon ties. C verify LOTQ is complete by trying to operate pumps. <br /> ❑ Closeiball valves or check valves on product piping. ❑ Disconnect electrical"bayonet"connectgr4om the STP(s). <br /> Lead Technic an Name ead hnidan I tore <br /> Genera!Safety Chks <br /> All site personnel ha. a been informed. l f <br /> Fuel delivery has balm informed. site Re ntativ Name site ve Signature <br /> Is a fuel delivery dud today? f <br /> LOTO procedures h ve been discussed and agreed. <br /> Work areas barricaded to protect workers,staff S public. have discussed- b elearanco form with technician,.— <br /> POS T-TES T <br /> echnician.POST-TEST PROCEDURES Check each Item com feted or mark — if not applicable) <br /> 1. ,��erno*all"LockoutlTagout"devices. <br /> 2. I� Hun all;pumps and verify there are no leaks: Fe Impact Valve Test Ports under dispensers <br /> J 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: Ll L2 L3 L4 L5 L6 <br /> 4. �I Check following components operational: [FATG probes, sensors, &caps <br /> ❑ .fall floats,dry breaks&caps ❑ Cathodic protection operational <br /> a dontainment sumps are dry Dispensers&POS operational <br /> R-10ispenser panels are replacedC �Drop tubes,fill adapters&caps <br /> ❑ Lieak detectors&vent tubes X Manhole covers and sump lids <br /> onitoring system is operational Shear valves are open <br /> ❑ siphon lines and manifold valves ❑ Siphon linos and manifold valves <br /> ❑ TP fittings and bayonet connectors L1Vents(not capped, plugged or isolated) <br /> 5. I-II Remote barricades. <br /> •.SIGN.OUT 9 OperatrVerificWoribf Wcrrtt O Lead Technician Name ad echniciarn si azure <br /> General Safety Ch ks: f/ <br /> Work area has been'left tidy&safe. l-{ <br /> Site staff are aware?f work status including any remaining isolation. se Repr Name ite Repr6gantarve Signature <br /> Changes to equipmnt are documented and communicated. <br /> All incidents, near in idents,and unsafe situations reported. 1, ` <br /> Site Representative Com ents: <br /> COMPANY CO FIDENTIAL O Tanknology Inc.,2011.All Rights Reserved. <br /> rintcd copies of this document are uncontrolled The current version is available in the Tanknoiogy On-Line Document Control System. <br /> i <br />