Attachment_B_-_Receiving_Offloading_Auth_Form.pdf

12.5% Sodium Hypochlorite (SH) Date Receiving / Off-Loading Authorization Form

Make copies of this form, weight scale certificate, signed bill of lading, and certificate of analysis WQCP A/P Admin Associate II’s Copies OPS Copies

ORIGINAL Bill of Lading, Weight Certificate, Certificate of Analysis COPY Bill of Lading, Weight Certificate, Certificate of Analysis

COPY Sodium Hypochlorite Receiving Form ORIGINAL Sodium Hypochlorite Receiving Form

During Off-Loading Time Delivery Started

10. Check all connections for leaks. Are connections leak-free?

• If no, stop immediately and safely secure the leaks before proceeding. □ Yes □ No

11. Maintain vigilance while observing all lines, hoses, and valves for leaks.

DOT regulations require an attendant to remain within 25’ during the unloading process □ Yes □ No

12. Have you stopped the unloading between the FULL and SPILL labels? □ Yes □ No

This form must be completed in full by both a qualified City of Palo Alto employee and the Sodium Hypochlorite delivery person prior to unloading. Failure to follow the precautions provided in the form will result in disciplinary action up to and including termination and/or the suspension of the business relationship with the supplier.

More importantly, failure to follow these precautions may result in personal injury to yourself or others in the work area. Authorization to proceed is not possible if any questions are answered as “NO”. However, if “NO” is an appropriate answer because other safeguards have been put in place, the Supervisor in charge or their designee must make a hand-written note to that affect and attach it to this form. If the Material Safety Data Sheets (MSDS) are not available, approval to proceed will not be given under any circumstances.

Prior to Off-Loading

1. Delivery being split requiring driver to make multiple connections

If Yes, Start with Tank 3. Finish with Tanks 1 & 2. Tractor Trailer turnaround at DMF is best with empty tank. □ Yes □ No

2. Barricades placed around chemical receiving area and delivery truck □ Yes □ No

3. Driver shown location of

1) Safety Shower 2) Eyewash Station 3) Chemical Spill Response Cabinet □ Yes □ No

4. Driver familiarized WQCP personnel with delivery tank Emergency Shutoff □ Yes □ No

5. Driver provided the Bill of Lading, Certificate of Analysis and Weight Certificate □ Yes □ No

6. WQCP personnel verified that chemical being received is Sodium Hypochlorite,12.5% □ Yes □ No

7. PPE donned by driver. Splash proof goggles or face shield, boots, gloves, hard hat □ Yes □ No

8. PPE donned by WQCP personnel

Chemical Face Shield w/chin guard, boots, neoprene gloves, hard hat □ Yes □ No

9. Receiving tank (s) can accommodate the amount of chemical being delivered SAFETY: Maintain 10% tank volume. MAX Tank Volume = 5,000gals

□ Yes □ No

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12.5% Sodium Hypochlorite (SH) Date Receiving / Off-Loading Authorization Form

Make copies of this form, weight scale certificate, signed bill of lading, and certificate of analysis WQCP A/P Admin Associate II’s Copies OPS Copies

ORIGINAL Bill of Lading, Weight Certificate, Certificate of Analysis COPY Bill of Lading, Weight Certificate, Certificate of Analysis

COPY Sodium Hypochlorite Receiving Form ORIGINAL Sodium Hypochlorite Receiving Form

After Off Loading Time Delivery Stopped

13. Are there any noticeable spills?

• If yes, review and follow WQCP procedures to begin spill cleanup □ Yes □ No

14. Inspect off-loading area. Secure receiving port using proper lockout/tagout device. □ Yes □ No

15. Collect all safety gear. and return it, clean and serviceable to storage cabinet. Lock Cabinet. □ Yes □ No

Printed Name Signature WQCP Senior/Supervisor/Operator TPOII

Printed Name Signature Delivery Driver

This form must be completed in full by both a qualified City of Palo Alto employee and the Sodium Hypochlorite delivery person prior to unloading. Failure to follow the precautions provided in the form will result in disciplinary action up to and including termination and/or the suspension of the business relationship with the supplier. More importantly, failure to follow these precautions may result in personal injury to yourself or others in the work area. Authorization to proceed is not possible if any questions are answered as “NO”. However, if “NO” is an appropriate answer because other safeguards have been put in place, the Supervisor in charge or their designee must make a hand-written note to that affect and attach it to this form. If the Material Safety Data Sheets (MSDS) are not available, approval to proceed will not be given under any circumstances.