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1 <br /> , r <br /> Tanknology Inc. <br /> 8501 N.MoPac Expressway,Suite 400 Austin,TX 78759 (800)964-0010 Policy 100-29-A <br /> Rev:D <br /> JOB CLEARANCE FORM t& Revised:8/04/2008 <br /> SITE SAFETY CHECKLIST-OVF <br /> Site Name/#: <br /> street W # <br /> ell <br /> &mew, <br /> Arrival Time: Departure Time: Travel Time: Others on site: Date <br /> Scope of Work and T s Performed(JSA's must be available for all tasks): <br /> Repairs o EquipmentWParts Pro . <br /> -Follow-up ac/tions required;equipment isolated;comments: <br /> l� <br /> PPE-PER!fBE7!7= <br /> IRED Check items used or mark--N nota icable <br /> Safety Vest Gloves ❑ Hearing Protection <br /> Boots Hard Hat ❑ Other <br /> ✓ PRE-TEST PROCEDURE$ Check each item completed or mark ^' ffnot a /icable <br /> 1. Discuss safety procedures with site personnel. Nearest hospital: <br /> 2. Prior to fuel deliveries the UST system must be placed back into working order. 909 <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 nozzles with"Out of Service"bags and nylon ties. ❑ Verify LOTO is complete by trying to operate pumps. <br /> ❑ Close ball valves or check valves on product piping. ❑ Disconnect electrical`itayonat"connector from the STP(s). <br /> Lew I echnician Name Lea Technician Signature <br /> e <br /> General Safety Checks: <br /> All site personnel have been informed. c,-� !l� <br /> Fuel delivery has been informed. de Representative Name epre ntativ ignature <br /> Is a fuel delivery due today? % <br /> LOTO procedures have been discus/ed—and agreed. 14re,:rO7-- <br /> Work areas barricaded to protect w rkers,staff&public. I have discussed job cle]&E form with technician. <br /> ✓ POST-TEST PROCEDURES (Check each item completed or mark — if not applicable) <br /> 1.. ❑ Remove all"Lockout/Tagout"devices. <br /> 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers <br /> 7 Leak Detector Threads on STP's 1 Functl iW <br /> 3. ❑ Install lead wire seal on all test plugs&leak detectors that were sifiiii <br /> Count LD threads: L1 L2 L3 L4 L5 91 aHa <br /> err Ln <br /> 4. 1 Check following components operational: ATG es,se s s,&ca <br /> Ball floats,dry breaks&caps Cath ti #- <br /> Containment sumps are dry Disp ers&POS operational <br /> Dispenser panels are replaced Drop tQbor. fill adapters <br /> Leak detectors&vent tubes Manhole covers and sump lids L t �4 <br /> Monitoring system is operational Shear valves are open <br /> Siphon lines and manifold valves Siphon lines and manifold valii,!es., tI%J,V° #, <br /> STP fittings and bayonet connectors Vents(not capped, plugged or isolated :3 <br /> 5.rt Remove barricades. <br /> Lead Technician Name ead Tech 'cian Signature <br /> General Safety Checks: <br /> Work area has been left tidy&safe. 6 s <br /> Site staff are aware of work status including any remaining isolation. gite Re resUntative Name ite a ure <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. <br /> Site RepresentativeComments: <br /> COMPANY CONFIDENTIAL ©Tanknology Inc.,2011.All Rights Reserved. <br /> Printed copies of this document are uncontrolled. The current version is available in the Tanknology On-Line Document Control System. <br />