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Work Order: 2257940 <br /> Tanknology Inc- I llolicv 100-29-A <br /> Stitt N.VOP'kc Expivt,s-ay.Su itr 400 AU563).TX 7 8 7 59 Rt!%-I'll <br /> Phow:4900)964-0010 Lacat:Lwzil:fiI2 i 4i I-63j4 1 Rci-i5ed:1 1--'02Q1)(16 <br /> SITE SAFETY CHECKLIST& <br /> OPERATOR VERIFICATION FORM <br /> Site Name: Address: W.O. <br /> Ir A,$ z 7'r <br /> CityeSTIZip: Dale., <br /> rr 7 <br /> Scope of Work: <br /> ltel"011-5 <br /> Parts&Materials Provided: <br /> Arrival Time: Departure Time: Travel Time <br /> PRE-TEST PROCEDURES POST-TEST PROCEDURES <br /> I Discuss safety procedures with site personnel. 1. Remove a It"LockouLfTago ut"devices- <br /> 2. Prior to fuel deliveries,the complete tank 2. Run all pumps and verity there are no leaks <br /> system to be placed back into working order. rider dispensers or in STP sumps. <br /> 3. / Secure entire work area with cones,flags,and Impact Valve Test Port <br /> caution tape or pennant flags. Leak Detector Threads <br /> 4.,/ Place fire extinguishers and"No$moking" Functional Eleme nt&Relief Screw <br /> jqns in he work area. 3. Install a lead wire seal on atl test plugs&leak <br /> n' <br /> -risers.and d rectors that 9./� <br /> All applicable pumps-dispensers, ec ors: a were serviced. Count LD threads: <br /> electrical breakers must be disabted during the Ll L2_ L3.__ L4 L5 <br /> test(s). 4. Ensure that all tank system components are <br /> 6. / *Turn off and secure the circuit breaker(s)with re to red to their original state(including): <br /> or <br /> .ko ut devices and tags. ATG probes,sensors,&caps <br /> Bali fl oats.dry breaks&caps <br /> 7. /,7 *Place"Out of Service'bags and nylon ties on <br /> dCathodic protection operational <br /> . <br /> dispenser nozzles. Containment sumps are dry <br /> 8. Verify Lockoutfragout procedure is complete Disoonsers&POS operational <br /> trying/ <br /> trng to operate pumps. <br /> by * Dispenser panels are replaced <br /> 9. (/ *Close ball valves or check valves on product Drop tubes,fill adapters&caps <br /> piping. Leak detectors&vent tubes <br /> 10. T "Remove the electrical"bayonet"connector Manhole covers and sump lids <br /> from the STP(s). <br /> Monitoring system is operational <br /> Shear valves are open <br /> uta pplies whan aco"sing product piping. <br /> Siphon lines and manifold valves <br /> Nearest Hospital: Spill onntainers&drain valves <br /> STP fittings and bayonet connectors <br /> 5. Remove cones,signs,and caution tape_ <br /> TanknologyTechnician Name Pre-Test Signature 1 Post-Test Signature <br /> Sito Rapresenlative Name Pre-Test Siqn.alura Past-Test Signature <br /> comments: <br /> A, <br /> CO-MPA.W CON'nDENTIAL :'s Tanknology hu,11106,.111 RiL*Ilu ke--rvcd. <br /> LnLal tapirs Oi�this Lk)cumen L are unctmtrn I led. <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />