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Tanknology Inc. 11000 N. MoPac Expressway, Suite 500 Austin, TX 78759 (800) 964-0010 Policy ] 00-29-A Rev: D �� JOB CLEARANCE FORM & Revised: 1/24/2014 SITE SAFETY CHECKLIST - OVF Site Name/#: Street Address: ldt� yUJ W.O. # Ir /"761/' /y7 Z3 / Arrival Time Departure Time: Travel Time: Others on site: Date ii �r -32 —10 Scope of Work and Tasks Performed (JSA's must be available for all tasks): /) Repairs to Equipment or Parts Provided: Follow-up actions required; equipment isolated; comments: Gk itis rP, SSLd PPE - PERSONAL PRO ECTIVE EQUIPMENT REQUIRED Check items used or mark — if notapplicable) ? Safety Vest Safety Glasses Gloves Hearing Protection Steel Toe Boots t I Splash Goggles ( Hard Hat Other ✓ PRE-TEST PROCEDURES (Check each item completed or mark ^ if not applicable) 1. Discuss safety procedures with site personnel. Nearest hospital: 2. `[' Prior to fuel deliveries the UST system must be placed back into working order. 3. -[r Secure entire work area with barricades (cones, flags, and caution tape, pennant flags, or other perimeter guard). 4. Place fire extinguishers and "No Smoking" signs in the work area. 5. ! : Implement Lockout[Tagout per API 1646 (when accessing product piping during tasks) L] All applicable equipment disabled during test(s). [ '.' Secure the circuit breaker(s) with lockout devices and tags. [ ; Secure nozzles with "Out of Service" bags and nylon ties. Verify LOTO is complete by trying to operate pumps. [ 1 Close ball valves or check valves on product piping. Disconnect electrical "bayonet" connector from the STP(s). SIGN IN Lead Technician Name Lead Technician Signature General Safety Checks: All site have been informed. personnel Fuel delivery has been informed. Site Representative Name Site Rep sen ti Signatu Is a fuel delivery due today? LOTO procedures have been discussed and agreed. NAKU M D LT �1 Work areas barricaded to protect workers, staff &public. I have discussed job clearance form with teth(tician. ✓ POST-TEST PROCEDURES (Check each item completed or mark ~ if not applicable) 1. Remove all "Lockout/Tagout" devices. 2.] Run all pumps and verify there are no leaks: C1 Impact Valve Test Ports under dispensers Leak Detector Threads on STP's ] Functional Elements & Relief Screws 3. J Install lead wire seal on all test plugs & leak detectors that were serviced. Count LD threads: L1 L2 L3 L4 L5 L6 4. Check following components operational: ATG probes, sensors, & caps [ ; Ball floats, dry breaks & caps C Cathodic protection operational [ _ Containment sumps are dry [ Dispensers & POS operational Dispenser panels are replaced ''[Z' Drop tubes, fill adapters & caps Leak detectors & vent tubes [ 1 Manhole covers and sump lids Monitoring system is operational [ 1 Shear valves are open [ ] Siphon lines and manifold valves [_l Siphon lines and manifold valves `' [ i STP fittings and bayonet connectors [ 1 Vents (not capped, plugged or isolated) 5. Remove barricades. SIGN OUT & Operator Verification of Work (OVF) Lead Technician Name Lead Technician Signature General Safety Checks: Work area has been left tidy & safe. Site staff are aware of work status including any remaining isolation. site Rep esentative Name Site Repr n e signature Changes to equipment are documented and communicated. All incidents, near incidents, and unsafe situations reported. L W L ./ Y lL(/ Site Representative Comments: 1 COMPANY CONFIDENTIAL © Tanknology Inc., 2011. All Rights Reserved. Printed copies of this document are uncontrolled. The current version is available in the Tanknology On -Line Document Control S stem.