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2098253893 ENGINEERING DEPT. 06 54 a.m. 09-10-2010 8/21 <br /> Work Order: 2276292 <br /> Tangnology Inc. <br /> 8501 N.MoPac Expressway,Suite 400 Austin,TX 78759 (800)964-0010 Policy 100-29-A <br /> JOB CLEARANCE FORM & Rev:e <br /> Revised:8/04l2008 <br /> SITE SAFETY CHECKLIST-OVF <br /> Site Name/#: Street Address: W.O. <br /> A AMe-A 7�7 W. ( O.Sd'ti Ir-Av'E ZZ70 Z42 <br /> Time: Tim: Travel Time: Others on site: Date <br /> Scope of Work and Tasks Performed(J 's must be avalible for all tasks): <br /> Nl&.1/72Fi2 S <br /> Repairs to Equipment or Parts Provided: <br /> Follow-up actions required;equipm. isolated;comments: <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check Items used or mark—N not <br /> Safety vest �K Safety Glasses Er Gloves ❑ Hearing Protection <br /> Steel Toe Boots ❑ S ❑ Hard Hat ❑ Other <br /> PRE TE T PRO EDURESCheck hitem gaMpkft or 0 <br /> if not <br /> 1. Ik /Discuss safety prtxedures with site personnel. Nearest hospital: sex <br /> 2. ❑ Prior to fuel deliveries the UST system must be placed back into w&king order. <br /> 3. Z Secure entire work area with barricades(cones,flags,and caution tape,pennant flags,or other perimeter guard). <br /> 4. Place fire extirjuishers and"No Smoking"signs in the work area. <br /> 5. ❑ Implement 1*koutlragout per API 1646(when accessing product piping during tasks <br /> ❑ All applicable equipment disabled during test(s). ❑ Secure the circuit breakers)with lockout devices and tags. <br /> ❑ Sec ire noes with"Out of Service"bags and nylon ties. ❑ Verity LOTO is complete by trying to operate pumps. <br /> ❑ Close ball valve or check valves on pr6ff'uct ' ' El Disconnect electrical"bayonet"connect«from the STP(s). <br /> IM �Tecema Lead T <br /> General Safety Checks: <br /> All site personnel have been informed. s <br /> Fuel delivery has been informed. <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. <br /> Wok areas barricaded to protect workers,staff&?wblic. - <br /> nenefi�m <br /> POST--TEST PROCEDURES(Checkeach item mf{letedormark ^ ynotacnlrca"_J <br /> 1. ❑ Remove all"LockoutfTagout"devices. <br /> 2. ❑ Run all pumps and verity there are no leaks: ❑ Impact Valve Test Ports under dispensers <br /> ❑ Leak Detector 17treads on STP s ❑ Functional Elements&Relief Screws <br /> 3. ❑ Install lead wire seal on all test plugs&leak detectors that were serviced. <br /> Count LD threads: Lt_ L2._ L3_ L4_ L5_ L6_ <br /> 4. Check following components operational: ❑ ATG probes,sensors,&caps <br /> ❑ Ball floats,dry breaks&caps ❑ Cathodic protection operational <br /> ❑ Containment sumps are dry ❑ Dispensers&POS operational <br /> ❑ Dispenser panels are replaced ❑ Drop tubes,fill adapters&caps <br /> ❑ Le#detectofs&vent tubes Manhole covers and sump lids <br /> Monitoring system is operational TJ Shear valves are open <br /> Siphon lines and manifold valves ❑ Siphon lines and manifold valves <br /> ❑ STP fittings and bayonq onnectors ❑ Vents(not capped,plugged or isolated) <br /> 5. Remove barricades:;:�- <br /> an Sivi"Ne <br /> General Safety Checks: <br /> Work area has beer�eft tidy&safe. <br /> Site staff are aware of work status including any remaining isolation. ne Repiesentalve me site <br /> Changes to equipment are documented and communicated. \ <br /> All incidents,near incidents,and unsafe situations reported. <br /> SAe apresentativecomments: <br /> COMPANY CONFIDEWTIAL ®Tanknology Inc.,2008.All]tights Reserves <br /> Printed copies of this document are uncontrolled.The current version is available in the Tankm On-Line <br /> Document Control S em r <br /> _ r <br /> a <br /> Tipknology Inc. 11000N.MoPac Expressway,Suite 500,Austin,Texas 78759 <br />