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W.O.# NW1-2338786 TanknoInc. I I UVO N.MaPae L•xpressway,,Suite s00 qq Au Austin,TX 78758 (800)964•0010 Policy I00-29-A JOB CLEARANCE FORM& Rev:F SITE SAFETY CHECKLIST—OW Revised:3/05/2018 Site Nemeth/.: '-1r. i 20 ca Street Address: W.O.p 3Z Anival Ti, Departuw'rlme: �� -1,1 C, Z 336 V. travel'rime: Others on site: Oate 11 scope of Wantl Tasks AertarmedJSA's t usl be available Or all tasks): Repairs to Equlpmem or Pa�Provided:t (�L Follow-up actions required;equipment isolated;commeNs: PPE-PERSONAL PROTE TIVE EQUIPMENT REQUlRED(Check- items used or mark—if not applicable) fety Vest Safety Glasses Gloves LI Hearing Protection I Steel Toe Boots ❑ SPlash Goggles ❑ Hard Hat ❑ Other ,./ ✓ PRE-TEST PROCEDURES Check ,'each if,m campleled or mark — ifnot a licable 1 .X� Discuss safety procedures with site personnel. Nearest hospital: 2, i_I Prior to fuel deliveries the UST system must be placed back into working order. 3. ❑ .Secure entire work area with barricades(cones,flags,and extension bars,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) ❑ Secure nozzles with"Out of Service"bags and nylon lies. ❑ Secure the circuit breaker(s)with lockout devices and tags. Close ball valves or check valves on product piping. ❑ Disconnect electrical"bayonet"connector from the STP(s). ❑ All applicable equipment disabled during test(s). ❑ Verify LOTO is complete by trying to operate pumps. SIGN IN Lead Technician Name LeatlTechnician Sigrialure General Safety Checks: All site personnel have been informed. Fuel delivery has been informed. Slle�epresentalive Name Is a fuel delivery due today? presentetive signature LOTO procedures have been discussed and agreed. ((A t t Work areas barricaded to protect workers,staff&public. I have discussed job clears a form with technician. ✓ POST-TEST PROCEDURES Check each item com feted or mark if ndt applicablej 1. ❑ Remove all"LockoutlTagout"devices. 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers ❑ Leak Detector Threads on STP's ❑ Functional Elements&Relief Screws 3. ❑ 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 ❑ Cathodic protection operational ❑ Containment sumps are dry n Dispensers&POS operational ❑ Dispenser panels are replaced ❑ Drop tubes,fill adapters&caps ❑ Leak detectors&vent tubes L, Manhole covers and sump lids ❑ Monitoring system is operational ❑ Shear valves are open ❑ Siphon lines and manifold valves ❑ Spill containers&drain valves ❑ STP fittings and bayonet connectors Cl Vents(not capped,plugged or isolated) F ❑ Remove barricades. tead Technlclan Name lead Technlydan Signature SIGN OUT&O erator Verification of Work(OVF) Safety Checks:ea has been left tidy&Safe. Repr enlptive NamaRepresentative Signature f are aware of work status including any remaining Isolation. to equipment are documented and communicated. Iii nts,near incidents,and unsafe situations reported.sentative Comments: ©Tartknology Inc.,2018,All Rights Reserved. COMPANY CONFIDENTIAL ontrolled. TJte cu rent version is available in the Tanknolo On-Line Document Control S stem. Printed copies of this docunlenl are one