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Tanknology Inc. Policy loo-29-A O 11000 N.MoPac Expressway.Suite 500 Austin,TX 76759 (800)964-0010 JOB CLEARANCE FORM&SITE SAFETY CHECKLIST-OVF ae°`Q Revised:v1 v2o19 z Site Name/#: Ireot A dress:(7,1 ✓G.C. oN IV Arrival ime' epa ure Time: Tra e' I e no: ate (.J.) Scope of Work and Tasks Performed(JSA's must ob available for all tasks): gs n %Q Repairs to Equipment or Pans Provided: Ib Follow-up actions required;equipment isolatetl;comments: ,t.o�ew.oe.t s, c r..d aM,w�—o r3,uW Prod wkd T7;pt1�✓��uWed• n kus�� cr, �� — �r Rad � 5 * ��E w PPE-PERSONAL PROTECTIVE EQUIPMENT REQUIRED Check✓items used or mark-if nota applicable) Safety Vest �t Safety Glasses ,iu Gloves ❑ Hearing Protection Steel Toe Boots [ Splash Goggles ❑ Hard Hat ❑ Other ✓ PRE-TEST PROCEDURES (Check ,'each item completed or mark - if not applicable) 1. Discuss safety procedures with site personnel. Nearest hospital: i 2. Prior to fuel delivenes the UST system must be placed back into working order. 3. ySecure entire work area with barricades(cones,flags,and extension bars,caution tape,pennant flags,or other perimeter guard). 4. Place fire extinguishers and"No Smoking"signs in the work area. 5. Confined Space Entry-If required complete separate CSE Checklist. If NO CSE REQUIRED check the following reason: ❑No CS's ❑CS's not opened 4o entry only visual )(No entry-used tools []Work from prone position w/o risk of falling in 6. ❑ Implement Lockout/Tagout 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"conned r from the STP(s). O ❑ All applicable equipment disabled during testis). ❑ Verify LOTO is complete by tryin o perate mps. G SIGN IN Lead Technician Name ad Tecnm nsi,nawre ~' General Safety Checks: , `, All site personnel have been informed. \,/U V Is a fuel delivery due today? ') �, site Representative Name a Repr a ive Si azure LOTO procedures have been discussed. �,.�P`/),. .�,ACS Work areas barricaded to protect workers,staff&public. "P�C!'I ✓ POST-TEST PROCEDURES(Check 'each item completed or mark - if not applicable) 1. Remove all"Lockout/Tagout"devices and nozzle bags/ties. 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: 1_1_ L2 L3 L4 1_5 1_6 4. d( Check following components operational: .E ATG probes,sensors,&caps v Ball floats,dry breaks&caps Cathodic protection operational n m $Containment sumps are dry Y Dispensers&POS operational rD N n r Dispenser panels are replaced Drop tubes,flapper valves,fill adapters&caps < v m e Leak detectors&vent tubes Manhole covers and sump lids (D 1�1 yMonitoring system is operational or Shear valves are open < N CSiphon lines and manifold valves open Y Spill containers&drain valves sv Q m STP fittings and bayonet connectors Vents&Extractors(not capped, g d ori fated) N 5. Remove barricades. r v SIGN OUT&Operator Verification of Work(OVF Lead Technician Name Lead a ici ignaure O W General Safety Checks: cc''I IG Iv✓XV- Work area has been left clean&safe. •so l -6 Site staff aware of work status Including any remaining isolation. Site Representative Namg s Represe aura n Changes to equipment are documented and communicated. �� O Tm All incidents,near Incidents,and unsafe situations reported. ic".11l3/'L� 2 Sita Representative Comments: to Is Is c COMPANY CONFIDENTIAL. U Tanknology Inc.,2019.All Rights Reserved. (, O 'nted copies of this documcnl:ua n molted.The current version is available in the Tanknology On-Line Document Control System r 0 � O ''0 III 0