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2098253893 ENGINEERING DEPT. 0 ;09 a.m. 09-10-2010 13/21 <br /> Work Order: 2276649 <br /> 17 <br /> 01OU Inc. <br /> li<fyt\.Atnpac Cxssvuv:Svity 1tlOhustin T?i?8?i9 (91101961-11010 Policy 1U0-29-.1 <br /> JOB CLEARANCE FORM & Revised: <br /> SITE SAFETY CHECKLIST—OVF I <br /> Site mellf: Street Address: W O. <br /> �as r{'�• 1 <br /> A a.e 'Glk 1 W.qastawt >c <br /> Arnval Tiffw. 010arture Tina: Tr"I� ime: Others on site: ate <br /> Scope of Work and Tasks Perforated(JSR's muni tta.available For ail tasks}: <br /> Repaira to Equipment or Farts rovided: <br /> i <br /> Follow-up actions required;e"prrt nl Isolated;comments: <br /> PPE•PERSONAL PRO TECTNE EQ(NPMENt REWIRED Chock Items used ar nark-N not a k <br /> Safety Vest Safety Glasses .t[ Gloves _ Heurk,y Prc>lra lknt <br /> Steel Toe Boots Splash G29or Hard Hat <br /> f CEQUR S icheck each from comalated or mark "if tier cab <br /> 1. Discuss safety procedures with site personnel. Nearest hospital; -� ® <br /> 2_ Prior to fuel deliveries the UST system must be placed back info working order_ <br /> 3. Ses:ure entirppvork area with barricades(cones,flags.and caution tape,pennant flags,or other pod meter guard). <br /> 4. V Place fire edii and"No Smoking"signs in the work areae- <br /> 3. Im "t LockoutfTagout per API 1646(when accessing product piping dulring tasks) <br /> Allapplicable equiprmA disabled during tasks). &' Secure ttr4 curuit breaker(s)with lockout devices and tags. <br /> JC Secure nozrtns++rith"Chi of Sonoco'bags and nylon ties. Jr, verily l OTO is complete by trying to operate purrs. <br /> Close two valves or tick valves 41kproduct piping. _ 01w. nnect olectric al'ibay +t°connector from the 5TI'N. <br /> t SIGN IN eau Iownician Name m+�f ri +cum yi u+lurr. <br /> General Safety Checks; <br /> All site lopmonnot have been informed. ,/ S <br /> Fuel delivery has been informed. Snr RWeaenW-de harm sit nrwww <br /> Is a W delivery due today? <br /> LO TO ptnoerkxes have been discussed and a.*erd. <br /> Work areas barricaded to prated•rankers,staff fl public. I Mora!discussed <br /> job form wilt tedtrtician. <br /> ✓ POST-TEST PR®CEDURES tcheak each ftt9m conmdcteC ar r»2rk "r ff nvr at>rvf+cabdel <br /> 1. Remove all"Lockoutriagout"devices. <br /> 2. Run all pumps and Verity there are no leaks: Impact Valve Test Ports under dispensers <br /> Leak Detector Threads on STD's Functional Elements&Relief Screws <br /> 3. _ Install lead wire seal on all test plugs&leak detectors that were serviced. <br /> Cotm LD threads: I-1_ •L2 L3_ L4_ L5 L6 <br /> 4, Check following components operational: ATG probes:sensors,&caps <br /> Bail floao,dry breaks&caps Cathodic protection operational <br /> Containfn . sumps are dry Dispensers&POS operational <br /> Dispenser panels are replaced Drop tubes,fig adapters&caps <br /> Leak detectors&vent tubes Mani ole covers and sump lids <br /> Monitoring system is operational Shear valves are open <br /> Siplion final w.4 maniWd valves Siphon lines and manifold valves <br /> STP fittings and bayonet connectors Vents(not capped,plugged or isolated) <br /> 5. t Remove barricades. <br /> SIGN OU7&2eerator Verification of Work OYF a AAd t ec""clan Nara teas a ntraan00ire <br /> General Safety C ecl s: <br /> Work arra has been left tidy&safe. <br /> Site staff are am <br /> ware of work status including any remaining isolation. s irersentaa Nano G' Rr pnaeure <br /> Changes to equipment are documented and commtsucated. <br /> All incidents,,tear incidents,and unsafe situations reported_ <br /> nit Rearesantaliw Mm-nem <br /> i <br /> t:t/btPANY CONVIDENT1 U. t,'tankmiloey Inc..29118 All Rights Reserved: <br /> Print.dc+ +esnFtttisLkt+mrcnl.rvvoonatrnlled lhccurrrntteraivnifmailahlctatlx tai+tuHGln.rClnLiuetkrrwttcntt:amrrnt5+gran <br /> s <br /> `f�nknology Inc. 11000 N.MoPac Expressway,Suite 500,Austin,Texas 78759 <br />