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Work Order: 2269825 <br /> `a �I <br /> Tanknology Inc. <br /> 8507 N.MoPac ExpreseweY.Suite 400 Austin,TX 78759 (800)969-0010 Policy 100-29-A <br /> JOB CLEARANCE FORM & Rev.° <br /> Revised:8/04/2008 <br /> SITE SAFETY CHECKLIST—OVF <br /> Site N treat Address: <br /> 2SArrCirc I oK CUA Coq 70C6.r11ve; cl ZZ& 002-5- <br /> Arrival <br /> ival Time: Departure Time: 7ravel Time: hers on Date <br /> 2Z Z1�1� /G- ZZ Zvi <br /> Scope of Work and Tasks Performed(JSA'a must be available for all tasks): <br /> ReL S ar CQ <br /> pans to quip n[ ons rovitled: <br /> S rfl G a S <br /> Folkav�rp actions required;equlpmen[�sciated;comments: <br /> PPE-PERSONAL P OTECT/VE EQUIPMENT REQINRED Cheek I ms used or mark-N not Icahfs <br /> Safety Vest Safety Glasses F9 Gloves ❑ Hearing Protectlon <br /> Steel Too Boots ❑ Splash Goggles ❑ Hard Hat I ❑ Other <br /> ✓ PRE-TEST PROCEDURES (Check each item cMaietrdormark — NnotaoWlcawal <br /> t <br /> 1. Discuss safety procedures with site personnel. Nearest hospital: T✓"w t Se{w cct <br /> 2. Prior to fuel deliveries the UST system must be placed back into working order.205, 52S- 374W <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 nates with"Out of Service'bags and nylon lies. 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 /> Lead Teenmoan Name Lead Taar.n ,nature <br /> General Safety Checks: p � ��'• <br /> All site personnel have been informed. r k t� %7L� <br /> Fuel delivery has been Informed. Site Represenlabw ams sne Representative Sgnature <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. <br /> Work areas barricaded to protect workers,staff&public. 1 � <br /> ✓ POST-TEST PROCEDURES Check Back Item co or mark — if notapplicable) <br /> 1. � Remove all"Lockoutfragout"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 /> b��nl9 Count LD threads: L1 L2 L3_ L4_ LS_ L6_ <br /> 4. I Check following components operational: /?ATG probes,sensors,&caps <br /> Ball floats,dry breaks&caps 11 Cathodic protection operational <br /> containment sumps are dry 11Dispensers&POS operational <br /> ❑ Dispenser panels are replaced i1`tPDrdp tubes,fill adapters&caps <br /> ❑ Leak detectors&vent tubes )_0 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 /> ❑ STP fittings and bayonet connectors Vents(not capped,plugged or isolated) <br /> 5. Remove barricades. <br /> " nician Name Lead TeChniaan 'gnature <br /> General Safety Checks: <br /> Work area has been left tidy&safe. Y�S <br /> Site staff are aware of work status including any remaining isolation. neeprese terve Name c eomsema 'g e <br /> Changes to equipment are documented and communicated. ' / <br /> All incidents,near incidents,and unsafe situations reported. V <br /> She Repmsemabva menta: <br /> COMPANY CONFUDENTUL C Tanlmology Inc.,2008.All Rights Reserved. <br /> Printed coies of this document are uncontrolled. The current version is available in the Tanknolo On-Line Document Control Sysien, <br /> Tanknology Inc. 11000 N.MoPac Expressway,Suite 500,Austin,Texas 78759 <br />