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Tanknology Inc . <br /> 11000 N. MoPac Expressway, Suite 500 Austin, TX 78759 ( 800 ) 964- 0010 Policy 100 -29-B <br /> INSPECTOR ONLY Rev : A <br /> SAFETY CHECKLIST - OVF <br /> Site Name/#: Street Address : City, State , and Zipcode: W. O. # <br /> PENSKE CA-043 800 E. Pescadero Ave . Tracy, CA 95376 AST-6703842 <br /> Arrival Time: Departure Time: Travel Time : Others on site : Date : <br /> 10 : 15 : 00 AM CDT 1 : 39: 00 PM CDT Jun 10, 2019 <br /> Scope of Work and Tasks Performed (JSA's must be available for all tasks) : <br /> AST 5 year CA PE inspection . <br /> Repairs to Equipment or Parts Provided : <br /> Follow-up actions required ; equipment isolated ; comments : <br /> PPE - PERSONAL PROTECTIVE EQUIPMENT REQUIRED (Check items used or mark — if not applicable) <br /> N Safety Vest N Safety Glasses N Gloves ❑ Hearing Protection <br /> N Steel Toe Boots ❑ Splash Goggles ❑ Hard Hat ❑ Other <br /> PRE- TEST PROCEDURES (Check each item completed or mark if not applicable) <br /> 1 . N Discuss safety procedures with site personnel . Nearest hospital : <br /> 2 . ❑ Prior to fuel deliveries the UST system must be placed back into working order. <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 /> SIGN IN Lead Technician Name Lead Technician Signature <br /> General Safety Checks : <br /> N All site personnel have been informed . Sandra Lawson <br /> ❑ Fuel delivery has been informed . <br /> ❑ Work areas barricaded to protect workers , staff & public. Site Representative Name Site Representative Signature <br /> ❑ Is a fuel delivery due today? Jose Frias <br /> I have discussed job clearance form with technician . <br /> POST- TEST PROCEDURES (Check each item completed or mark if not applicable) <br /> 1 . ❑ Run all pumps and verify there are no leaks : <br /> ❑ Impact Valve Test Ports under dispensers ❑ Leak Detector Threads on STP's ❑ Functional Elements & Relief Screws <br /> 2 , N Confirm location was returned to pre-arrival state <br /> 3 . ❑ Remove barricades <br /> SIGN OUT & Operator Verification of Work (OVF) Lead Technician Name Lead Technician Signature <br /> General Safety Checks : <br /> N Work area has been left tidy & safe Sandra Lawson <br /> ❑ Site staff are aware of work status including any remaining isolation <br /> Site Representative Name Site Representative Signature <br /> N Changes to equipment are documented and communicated <br /> ❑ All incidents , near incidents , and unsafe situations reported Jose Frias <br /> w <br /> Site Representative Comments : <br />