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i <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 & Revised:8/04/2008 <br /> SITE SAFETY CHECKLIST-OVF <br /> Site Namel#: Street Address: W.Q.# <br /> Arrival Time: Dep/aRur T/i�me: ravel Time: Others on site: Datat�e 5^ z <br /> -11 <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): <br /> Repairs to EqCtipmedt or Pdfts Provided: <br /> !u za c+Q0 6,9 ,'- o <br /> Follow-up actions required:equipmOnt isolated;comments: <br /> 1 - d68 <br /> PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check items used or mark—ff not app llcabre <br /> JFtr Safety Vest 4W, Safety Glasses 4K Gloves ❑ Hearing Protection <br /> Steel Toe Boots I ❑ Splash Goggles I I ❑ Hard Hat ❑ other <br /> ✓ PRE-TEST PROCEDURES (check each nem completed or mark ^- if not aAalica_ble) <br /> 1. Discuss safety procedures with site personnel. Nearest hospital: Si,76-Z ;�Z.w <br /> 2. Prior to fuel deliveries the UST system must be placed back into working order. 700j _93$' -j.Sbb <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`bayonet"connector from the STP(s). <br /> Lead Technician Name Lead TechnlaanSignature <br /> General Safety Checks: <br /> All site personnel have been informed. <br /> Fuel delivery has been informed. Site Representative Name R preve Signature <br /> Is a fuel delivery due today? r <br /> LOTO procedures have been discusised and agreed. <br /> Work areas barricaded to protect workers,staff&public. <br /> .;lt> :ci _. ab salaries fomii; t <br /> ✓ POST TEST PROCEDURES(Check each item completed or mark if not applicable) <br /> 1. ❑ Remove all"LockoutfTagout"devices. <br /> 2. ❑ Run all pumps and verify there are no teaks: ❑ Impact Valve Test Ports under dispensers <br /> ❑ Leak Detector Threads 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: L1_ L2_ L3 L4 L5_ LIS_ <br /> 4. t6?" Check following components operational: ATG probes,sensors,&caps <br /> Ball floats,dry breaks&caps Cathodic protection operational <br /> Containment sumps are dry �K Dispensers&POS operational <br /> Dispenser panels are replaced Drop tubes,fill adapters&caps <br /> Leak defectors&vent tubes Manhole covers and sump lids <br /> Monitoring system is operational Shear valves are open <br /> Siphon lines and manifold valves Siphon lines and manifold valves <br /> STP fittings and bayonet connectors Vents(not capped,plugged or isolated) <br /> 5. A( Remove barricades. <br /> Lead Technician Name Lead Tephnician Signature <br /> General Safety Checks: [ <br /> Work area has been left tidy&safe, r�Z�I& (J"/LL6yr� <br /> Site staff are aware of work status including any remaining isolation. Site Representative Name Site Representative Signature <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. 4t,1��11 �G'✓�� <br /> Site Representative Comments: <br /> COMPANY CONFIDENTIAL ©Tanknology Inc.,2011.All Rights Reserved. <br /> tinted co ies of this document are uncontrolled. The current version is available in the Tanknology On-Line Document Control S stem <br />