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Received on 1023/2019 <br /> SJC EHD - CR <br /> Tan Suite 50 y Inc. <br /> 11000 N. MoPac Expressway,Suite 600Austiq TX 78759(800) 964-0010 policy 100-29-B <br /> INSPECTOR ONLY Rev:A <br /> 419 SAFETY CHECKLIST - OVF <br /> Site Name/#. Street Address: City,Slate,and Lpcotle: W.O.# <br /> ADVANCEGEO ENV SILVA TRUCKING M Vis Mathews Read French Camp,CA 95231 AST4703484 <br /> Arrival Time: Departure Tame: Travel Tune: Others on site: Date: <br /> 8:16 M AM PDT 9:30:00 AM PDT I Apr 2Q 2019 <br /> Scope of Mirk and Tasks PerRxmetl(d s must be available for all tasks): <br /> AST Formal SPI)i inspection. <br /> Repairs to Equipm enl or Paris Provided: <br /> Follow-up actions required;equipment isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED(Check items used or mark-if riot applicable) <br /> 0 Safety Ved M Safely Glasses A Gloves ❑ Hearing Protection <br /> 0 Steel Toe Bods ❑ Splach Goggles ❑ Hard Hal ❑ Other <br /> PRE-TEST PROCEDURES (Check each item completed or mark- if not applicable) <br /> 1. A Discuss safely procedures with site personnel.Nearest hospital: <br /> 2. ❑ Priorto fust deliveries ere DST system mus be placed back into working order. <br /> 3. ❑ Secureenike wodkareawiih barricades(cones,flags, and caution We,pennant flags,ordherpenmeler guard). <br /> 4. ❑ Place fire extinguishers and"No Smoking"signs in the work area. <br /> SIGN IN Lead Technician Name Lead Technician Signature <br /> General Safety Checks: <br /> A All site personnel have been informed. Sandra Lawson - .= <br /> ❑ Fueldeliveryhasbeen informetl. <br /> ❑ Work areas baricadetl to protect workers,saff&public. Site Rep resonlakne Nam a Site Representative Signature <br /> ❑ Is a fuel delivery due today? Rene Schmidt <br /> I have discussed job clearance form with technician. <br /> POST-TEST PROCEDURES (Check each item completed or mark- if not applicable) <br /> 1. ❑ Run all pumps and verify thereare no leaks: <br /> ❑Impact Valve Test Pats under dispensers ❑Leak Selector Threads on STP's ❑Functional Elements&Refief Screws <br /> 2. px Confirm location was returned to pre-arrival sate <br /> 3. ❑ Removebanicades <br /> SIGN OUT&Operator Verirmation of Work(OVF) Lead Technician Name Lead Technician Signature <br /> General Safety Checks: <br /> px Work area has been left tidy&safe Sandra Lawson v_ <br /> ❑ Site staff are aware of work status including any remaining isolation <br /> Site Representative Name Site Repreuntative Signature <br /> ® Changes to equipment are documented!and communicatetl <br /> ❑ All inddents,near modems,and unsafe situations reported Rene Schmidt 1-4 . <br /> Site Representative Comments: <br />