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W.O.# NW1-2321928 <br /> `fnnknolog.v Inc. <br /> "IN ht„#'m;I tr�R Saar.jnlh 4W A-1 Ill.I\787" 0111))*44111lre E•'nlla'Y IIM-29-A <br /> JOB CLEARANCE FORM & Rev:u <br /> HeYr�tt:sculgr2r>trs <br /> L_ 'SA CIIECKt.IST—OVF <br /> to A!a la a uat ddtesa: _ <br /> -4 -� _ s � �_ <br /> Arnvat km: Pa+tu ravel Imie. - Ihers Uri site! rile <br /> 115e*?I- J. <br /> AW u V,,4//OM attli Asks PerfL>rnled;JSA sg invsj W avillab:u fut all Iasks; <br /> s fa€slur <br /> pmanl a errs alar� - -....� <br /> CALM <br /> eq eQutpmenl Isohatntl:onmmanls <br /> PPE-PERsoriAL PRofEc ffyE EQUIPMENT REQUIRED Chock!turns used or noarh�if rrof a !!cable <br /> s^ Safety Vest "—""Safety Glasses �Oloves <br /> I,H,1 r <br /> crcus f Hearing Prolection <br /> sae I3Spfa!:h Gaxlgles <br /> ' Word Wnt ! ! Olhor......... <br /> PRC7CEDUF2ES Cnack earn ifattr compfprad or rrrark Il oat appecabfa <br /> f salary <br /> Prix to fuef deli nes the UST systamures wilt,s116 r <br /> sonnel. Nearest hospital: <br /> 3. Must be placed back into working order. <br /> f SOOLIM entire work area with barricades(cones,flags,and caution tape,pennant flags,or other perimeter guard). <br /> 4. PtaCa fire exrinqulshers and'No Smoking"signs in the work area. <br /> 5 Implement Lockout(Tagout per API 1546(when accessing product piping curing tasks) <br /> Arf a c'aLd®WgUIP r7ent disabled during test(s). 1Secure the clrcult breakers)with lockout devices and tags. <br /> Sutwfv mules vrith'Out of Service"bags and nylon ties. 1} Verify LOTO Is cam eta by trying to op ate pumps. <br /> Cicrle ball vafYrS or['.fleck valves on product piping. Disconnect elorl .af" ayonel`[cone[ r from the, Fsl. <br /> SIGN IN LnnQ achixc��sn n�a <br /> General 5alety Checks: <<En utj,..u0 talu,u <br /> All site personnel have been tnformed. <br /> - e!delivery has been infortnal, <br /> Is a fuel delivery due belay? iM Iinr,ruan unu wW„�,n a esensai vo ,a, <br /> LOTO procedures have been doscussod and agreed. c <br /> Work areas barricaded to protecl workers.stuff&public. <br /> i lieu d. ussrad ub clearance form with ti nfrl <br /> ✓ POST TEST PROCEL7URES Check aaclr! n.rem farad or mark M !r not a ucaba <br /> 1. Remove all"Lockouvfagout"devices. <br /> 2_ Run all pumps and verify there are no leeks Impact Valve Test Ports under dispensers <br /> .i Leak Detector Threads on STP's f ; Functional Elements&Relief Screws <br /> 3. ; Install lead wire seal on all test plugs&teak detectors that were serviced, <br /> Count LD threads: L f_ L2_ L3___Y. L4 L5_ L6_ <br /> 4. Check fvflowing components operational: i_jATG probes,sensors,&caps <br /> 1 Sal)floats,dry breaks&caps i j Cathodic protection operational <br /> Containment sumps are dry f , Dispensers&POS operational <br /> Dispenser panels are replaced Drop tubes,fit!adapters&caps <br /> C J Leak detectors&Vent tubes !,1 Manhole covers and sump lids <br /> 1 l Monitoring system is operational f.! Shear valves are open <br /> Siphon fines and manifold valves i Siphon fines and manifold valves <br /> STP fittings and bayonet connectors ents(noca ped,plugged Of isolat d) <br /> a• Remove barricades <br /> SIGN OUT&Operator Verification of Work(O Mid fachnic n a. o tr 7,t <br /> rneral Safety Checks: w,. Hyrw4ue <br /> irk area has been Jet!lily&safe, <br /> a staff are aware of work status including any remaining isolation. „„M1ant <br /> inges to equipment are documented and communicated. 1°0e la <•rr;senlar,�c 'ryl ae <br /> ncidents,near incidents,and unsafe situations reported, <br /> tepresentaitva ommenl9: <br /> )f1IPArYY C(1NFIUENTIAL rs 1'llnl,nology Inc..2M 1.All Riy)lts Rrx'rv,cd. <br /> Prdnted l'U i1:S IAt fh18 dal'tlFlti:al arc iln4'llillrolled. The oinyui version I.%JS:Ill;lhie in Illi I'1nk11alVl;y C)Ei-t.ilrC[k K:Unit 111(- untfrrt$1 C <br /> f - �L� t L <br /> OWf MAY 4 4 Z015 <br /> ENVIRONMENTAL <br /> 'yr_+�rtirN r1C09t7TlIAC�t� <br />