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W.O.# NW1-2338552 Tanknology Inc. 11000 N.IvloPac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Policy 100-29-A JOB CLEARANCE FORM& Rev:F Revised:3/05/2018 SITE SAFETY CHECKLIST—OVF Site Namef#: Street Address: W.O.# —( 30-140 c 233Ss�`r Arrival Time. Departure Time: Travel Time: Others on site,. Dete G I o 16).l1'7fi Scope of Work and Tasks Performed(JSA's must be available for all tasks): Pd v / Repairs to Equipment or fPPa�rtts Provided: r n Fo]ew-p actions required;equipment isolated;comments: `OP Q Y as P2 PPE-PERSONAL PROTECTIVE EQUIP ENT REQUIRED(Check "Hems used or mark—if notapplicable) Safety Vest 'SrSafety Glasses Gloves Ll Hearing Protection Steel Toe Boots ❑ Splash Goggles 1 ❑ Hard Hat ❑ Other ✓ PRE-TEST PROCEDURES (Check ,each item completed or mark -- if not applicable) 1. 1�- Discuss safety procedures with site personnel. Nearest hospital: 2. 14' Prier 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. Place flre extinguishers and"No Smoking'signs in the work area. 5. Implement LockoutlTagout per API 1646(when accessing product piping during tasks) 'Secure nodes 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). a Verify LOTO is complete by trying to operate pumps. SIGN IN - Lead Technician Name Lead Technician Signature General Safety Checks: All site personnel have been informed. Fuel delivery has been informed. Site Representative Name site R sentavve Signature Is a fuel delivery due today? LOTO procedures have been discussed and agreed. �Aj q� ' a%kt'Kr, Work areas barricaded to protect workers,staff&public- I Have discussed job clearance form ith 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 1-2 L3 L4— LS— L6 4. 11Check following components operational: 11ATG probes,sensors,&caps ❑ Ball floats,dry breaks&caps D Cathodic protection operational ❑ Containment sumps are dry Ll Dispensers&POS operational ❑ Dispenser panels are replaced Q Drop tubes,fill adapters&caps ❑ Leak detectors&vent tubes ❑ Manhole covers and sump lids r<Monitoring system is operational D Shear valves are open ❑ Siphon lines and manifold valves ❑ Spill containers&drain valves ❑ STP fittings and bayonet connectors ❑ Vents(not capped,plugged or isolated) 5. Remove barricades. SIGN OUT&Operator Verification of Work(PVF) Lead Technician 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. Site Rftresefttative Name de Repi-pSentative Signature Changes to equipment are documented and communicated. �(] ! All incidents,near incidents,and unsafe situations reported. 5 0Lt.Or IA C ASf-d Site Representative Comments: 1 COMPANY CONFIDENTIAL ©Tanlmology Tne_,2018.All Rights Reserved. T rated copies of this document are uncontrolled. The current version is available in the Tatilmolo On-Line Document Controls stem.