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W.O.# NW1-2337736 Tanknology Inc. policy 100-29-A 11000 N.MoPac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Rev:F JOB CLEARANCE FORM& Revised:3/05/2018 SITE SAFETY CHECKLIST—OVF Wo.n Site Name* Street Ad resa: 33 �S4/ Trainva m. parture me: rave me : ate cope of workand Tasks Performed( s mut be available for all lee e): spam to u p ent or arts V i t-oll".U..required;equipment isolated;comments: PPE-PERSONAL PROTECTIVE QUIPMENT REQrREDCheck✓items used or mark–If t a Ifcable B'Safety Vest a Safety Glasses oves El Hearing Protection Steel Toe Boots El Splash Goggles rd Hat ❑ Other ✓ PRE-TEST PROCEDURES (Check✓each item completed or mark – if not applicable) 1. 4Discuss safety procedures with site personnel. Nearest hospital: 2. 17J Prior to fuel deliveries the UST system must be placed back into working order. 3. ;""Secure entire work area with barricades(cones,flags,and extension bars,caution tape,pennant flags,or other perimeter guard). 4. El"Place fire extinguishers and"No Smoking"signs in the work area. 5. ❑ Implement LockoutlTagout per API 1646(when accessing product piping during tasks) ❑ Secure nozzles with"Out of Service'bags and nylon ties. ❑ Secure the circuit breaker(s)with lockout devices and tags. ❑ Close ball valves or check valves on product piping. ❑ Disconnect electrical"bayonet"connector from the STP(s). ❑ All applicable equipment disabled during test(s). V rify LOTO is complete by trying to operate pumps. "SIGN IN" b "` ad Techni ian Name Lead Technician Signature General Safety Checks: All site personnel have been informed. Fuel delivery has been Informed. i resenta' ame Site Representative Signature Is a fuel delivery due today? LOTO procedures have been discussed and agreed. QQ{J I,S Q�{ Work areas barricaded to protect workers,staff&public. I have discussed'ob clearance form with technician. ✓ POST-TEST PROCEDURES(Check✓each item completed or mark - if not applicable) 1. ❑ Remove all"Lockout/Tagout"devices. 2. ❑ Run all pumps and verify there are no leaks: ❑ Impact Valve Test Ports under dispensers ❑ Leak Detector Threads on STP's ❑ Functional Elements&Relief Screws 3. ❑ Install lead wire seal on all test plugs&leak detectors that were serviced. Count LD threads: L1_ L2_ L3_ L4— L5_ L6_ 4. /Check following components operational: ❑ ATG probes,sensors,&caps ❑ Ball floats,dry breaks&caps ❑ Cathodic protection operational ❑ Containment sumps are dry ❑ Dispensers&POS operational O'Dispenser panels are replaced ❑ Drop tubes,fill adapters&caps ❑ Leak detectors&vent tubes ❑ Manhole covers and sump lids 'Monitoring system is operational ❑ Shear valves are open ❑ Siphon lines and manifold valves ❑ Soill containers&drain valves ❑ STP fittings and bayonet connectors nts(not capped,plugged or isolated) 5. 0 Remove barricades. SIGN OUT&Operator Verification of Work(OVF) T nician Name Lead Technician Signature General Safety Checks: Work area has been left tidy&safe. Site staff are aware of work status including any remaining isolation. a Represent tive a e Site Representative Signature Changes to equipment are documented and communicated. p* All incidents,near incidents,and unsafe situations reported. L to Representative omments: COMPANY CONFIDENTIAL ©Tanknology Inc.,2018.All Rights Reserved. tinted co ies of this document are uncontrolled.The current version is available in the Tanknolo On-Line Document Conhol S stem,