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W.O.# NW1-2353287 <br />- Tanknology Inc. Policy 100-29-A <br />11000 N. MoPac Expressway, Suite 500 Austin, TX 78759 (800) 964-0010 Rev: G <br />1419 JOB CLEARANCE FORM & SITE SAFETY CHECKLIST - OVF Revised: 2/11/2019 <br />Site Name/#: <br />Stryyet Adtlress: <br />w.0. It <br />Zjr-3Z <br />Arrival Time: <br />Departure Time: <br />Travel Time: F <br />Site Representative Name <br />Date <br />Is a fuel delivery due today? �_ <br />-OTO procedures have been discussed. <br />PPE - PERSONAL PROTECTIVE EQUIPMENT <br />Safety Vest efety Glasses. <br />Steel Toe Boots 111 Splash Goggles <br />✓ PRF-TFST PR[)CFn11RFS lrhnri <br />?UIRED Check <br />Gloves <br />❑ Hard Hat <br />each item a <br />.,'items used <br />❑ Hearing Protection <br />❑ Other <br />or mark - if not app) <br />1. ❑ Discuss safety procedures with site personnel. Nearest hospital: 1Y I <br />to fuel deliveries the UST system must be placed back into working order. <br />cu <br />entire work area with barricades (cones, flags, and extension bars, caution tape, pennant flags, or other perimeter guard). <br />��e <br />e extinguishers and "No Smoking" signs in the work area. <br />d Space Entry — If required complete separate CSE Checklist. If NO CSE REQUIRED check the following reason: <br />o CS's ❑CS's not opened ❑No entry only visual o entry - used tools ❑Work from prone position w/o risk of falling in <br />❑ Implement Lockout/Tagout per API 1646 (when accessing product piping during tasks) <br />❑ S e nozzles with "Out of Service' bags and nylon ties. ❑ Secure the circuit breaker(s) with lockout devices and tags. <br />Close ball valves or check valves on product piping. ❑ Disconnect electrical "bayonet" connector from the STP(s). <br />❑ All applicable equipment disabled during test(s). Verify LOTO is complete by trying to operate pumps. <br />General Safety Checks: <br />have been informed. <br />All site personnel <br />Site Representative Name <br />site Representative Signature <br />Is a fuel delivery due today? �_ <br />-OTO procedures have been discussed. <br />✓York areas barricaded to protect workers, staff & puU7c. <br />✓ POST-TEST PROCEDILRE �r=each item completed or mark if not applicat <br />1. - Remove all °Lockout/Tagout" devices .art ,,=:i <br />; varsities, <br />2. ❑ Run all pumps and verify there are no leak <br />❑ Impact Valve Test Ports under dispensers <br />Leak Detector Threads on STP's <br />❑ Functional Elements & Relief Screws <br />3. ❑ Install lead wire seal on all test plugs & leak detectors that were serviced. <br />Count LD threads: Li L2 L3 <br />L4 __ L5 L6 <br />4. - Check following components operational: <br />❑ ATG probes, sensors, & caps <br />- Ball floats, dry breaks & caps <br />❑ Cathodic protection operational <br />- Containment sumps are dry <br />❑ Dispensers & POS operational <br />Dispenser panels are replaced <br />❑ Drop tubes, flapper valves, fill adapters & caps <br />Leak detectors & vent tubes <br />❑ Manhole covers and sump lids <br />5 Monitoring system is operational <br />❑ Shear valves are open <br />= Siphon lines and manifold valves open <br />❑ Spill containers & drain valves <br />STP fittings and bayonet connectors <br />❑ Vents & Extractors (not capped, plugged or isolated) <br />5. - Remove barricades. <br />SIGN OUT & Operator Verification of Work (OVF) <br />Lead Technician Name lead Technician Signature <br />neral Safety Checks: <br />/tip <br />Dirk area has been left clean & safe. <br />e staff aware of work status including any remaining isolation. <br />Site Representative Name Site Repres un <br />anges to equipment are documented and communicated. <br />incidents, near incidents, and unsafe situations reported. <br />' <br />COMPANY CONFIDENTIAL © Tanknology Inc., 2019. All Rights Reserved. <br />tinted co ies of this document are uncontrolled. The current version is available in the Tanknoloa On -Line Document Control S stem. <br />Ovf <br />