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W.O.# NW1-2362525 Cust Ref# : 246417966 I Tanknology Inc. { I 11000 N.MoPac Expressway,Suite 500 Austin,TX 78759 (800)964-0010 Policy 100-29-A vl JOB CLEARANCE FORM&SITE SAFETY CHECKLIST-OVF Rev:G r Revised:Z]I/2019 114 ire Name/H: eatA cess: �z'.J Amval ir:�� -� Dep`e.n�ure lime: '[l tf.�G7 lurs ongsn(e- me . T,51196 �5��aeme ate Scpe oftwlo, antl�sks Performed(JSA's must oe available for all tasks)�I 7r Repairs to quipment or Pans Provide � t ' �tu'S � l.S //i is fiiJ�yJr`G l� (tf ( ; AJ l t 2. ` Follow_up actions regain,..egeipment isyola�ted;comments: `� it L tRras n4A. abCt, t1 t tR ot/ny OC �irytp S PPE-PERSONAL PROTECT/VE EQUIPMENT REQUIRED Check-,items used or mark-if nota licable Safety Vest K Safety Glasses Steel Toe Boots ❑ Gloves ❑Goggles Hard Hat Hearing Protection Splash ❑ ✓ er PRE-TEST PROCEDURES Check✓each item com /eted or mark -if nota licable 1 �y Discuss safety procedures with site personnel. Nearest hospital:_ Z//7 2. '1 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. C 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: ❑ WorkNo CS's ❑CS's not opened ❑No entry only visual ❑No entry-used tools ork from prone position w/o risk of falling in 6. ❑ Implement LockoutiTagout 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). ❑ Verify LOTO is complete b tr in t o erste SIGN IN Lead Technician Name y trying p ps' General Safety Checks: a Technici All site personnel have been inform)b/ r ure Is a fuel delivery due today? /LJ LOTO procedures have been discussed. site Representative Name Work areas barricaded to protect workers,staff&public. ` site Repres v si atu ✓ POST-TEST PROCEDURES Check✓each item comlate.or ark 1• Remove all"Lockout/Tagout"devices and nozzle bags/ties. tf not—ARpEcabije 2. Run all pumps and verify there are no leaks: Impact Valve Test Ports under dispensers Leak Detector Threads on STP's Functional 3. Install lead wire seal on all test plugs&leak detectors that were servicedlments&Relief Screws Count LD threads: L1 L2_ L3_ L4 4. (Js Check following components operational: — L5— L6— Ball floats,dry breaks&caps ❑ ATG probes,sensors,&caps ❑ Cathodic protection operational Containment sumps are dry Dispenser panels are replaced Dispensers&POS operational Leak detectors&vent tubes fV Drop tubes,flapper valves,fill adapters&caps Monitoring System is operational - SheaManole covers and sump lids Siphon lines and manifold valves open Shear valves are open p ❑ Spill c ntainers&drain valves STP fittings and bayonet connectors ❑ Ve &Ext actors(not capped,Plugged 5. d Remove barricades. gged or isolated) SIGN OUT&Operator Verification of Work(OVF) a Technlcl ame General Safety Checks: ead Technician Signature Work area has been left clean&safe. o Site staff aware of work status including any remaining isolation. i a Represe t ive NameI ve Changes to equipment are documented and communicated. site Representative signature All incidents,near incidents,and unsafe situations reported. Site Representative Comments: G '� t7'' COMPANY CONFIDENTIAL Tanl:nology Inc.,2019.All Rights Reserved. 'rioted co ies of this document are uncontrolled. The current version is available in the Tanknolo �On-line Document Control S tem.