Laserfiche WebLink
Tanknology Inc. <br /> 11000N.MoPac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Policy 100-29-A <br /> JOS' CLEARANCE F® & Rev:D <br /> ' <br /> SITE SAFETY CHECKLIST—OVF Revised: 1/24/2014 <br /> Site Namef#: o1161. Street Address:t-.3q E•Yor'tmr 'L A✓e W.O.# <br /> L.trt.x+J YoYt 1t.tcrK�er,� r,.L, J oA 233 4 3�{D <br /> Arrival Time: Departure Time: Travel Time: Others on site: Date <br /> Scope of Work and Tasks Performed(JSA's must be available for all tasks): ��<.r--®✓- -��IS,Q, �t <br /> Repairs to Equipment or Parts Provided:04, <br /> Follow-up actions required;equipment isolated;comments:$ <br /> PPE-PERSONAL P12OTFrTIVE ECIUIPMENT REQU)R D Check items used or mark-if not licable <br /> L1 Safety Vest Safety Glasses Gloves n Hearing Protection <br /> L� Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other <br /> ✓ PRE-TEST PROCEDURES (Check each Item ccompleted or mark — if not applicable) <br /> 1Discuss safety procedures with site personnel. Nearest hospital: /1/ <br /> 2. Prior to fuel deliveries the UST system must be placed back into working order. <br /> 3. [V Secure entire work area with barricades(cones,flags,and caution tape,pennant flags,or other perimeter guard). <br /> 4. [i Place fire extinguishers and"No Smoking"signs in the work area. <br /> 5. Implement LockoutfTagout 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 /> SIGN IN Lead Technician Name ad Technician Sig lure <br /> General Safety Checks: a <br /> All site personnel have been informed./ ,SQ�l✓K� ' <br /> Fuel delivery has been informed. �)C�a, Site Representative Name Site Representative ignature <br /> Is a fuel delivery due today? <br /> LOTO procedures have been discussed and agreed. <br /> Work areas barricaded to protect workers,staff&public. I have discussed IL <br /> clearance form with technician. <br /> POST-TEST PROCEDURES(Check each item completed or mark if not applicable) <br /> 1. [i Remove all"Lockout/Tagout"devices. <br /> 2. LI Run all pumps and verify there are no leaks: [I Impact Valve Test Ports under dispensers <br /> [I Leak Detector Threads on STP's 1.1 Functional Elements&Relief Screws <br /> 3. C] Install lead wire seal on all test plugs&leak detectors that were serviced. <br /> Count LD threads: L1 L2 L3 L4 L5 L6 <br /> 4. G� Check following components operational: ( 'ATG probes,sensors, &caps <br /> ❑ ball floats,dry breaks&caps ❑ Cathodic protection operational <br /> [�'Containment sumps are dry I/ Dispensers&POS operational <br /> V Dispenser panels are replaced I I Drop tubes,fill adapters&caps <br /> V Leak detectors&vent tubes [r, Manhole covers and sump lids <br /> C Monitoring system is operational [Shear valves are open <br /> ❑ tiphon lines and manifold valves ❑ Siphon lines and manifold valves <br /> ❑ STP fittings and bayonet connectors ❑ Vents(not capped,plugged or isolated) <br /> 5. Remove barricades. <br /> SItaN ou ,9,0' 'stair Verifi tion.of Nwt)rk EIY Lead Technician Name I Aad Technician ig ture <br /> General Safety Checks: '�t <br /> Work area has been left tidy&safe. Su t✓Gt1/ <br /> Site staff are aware of work status including any remaining isolation. Site Representative Name Site Represent ' e ignature <br /> Changes to equipment are documented and communicated. <br /> All incidents,near incidents,and unsafe situations reported. p� �, <br /> Site Representative Comments: <br /> COMPANY CONFIDENTUL ©Tanknology Inc.,2011.All Rights Reserved. <br /> Printed copies of this document are uncontrolled. The current version is available in the Tanknolo On-Line Document Control System <br />