Offloading_Form.doc
DOC document 93 KB Posted
- Attached to
- Bulk 12. 5% Sodium Hypochlorite and Delivery
- Solicitation number
- RFQ197475
- Issued by
- Santa Clara County, California
About this file
This document is an Off-Loading Authorization Form issued by the City of Palo Alto's Regional Water Quality Control Plant (RWQCP) for the receipt and delivery of 12.5% Sodium Hypochlorite. The form establishes standardized safety and operational procedures that must be completed in full by both a qualified City of Palo Alto employee and the sodium hypochlorite delivery personnel prior to unloading. The RWQCP estimates annual sodium hypochlorite consumption at approximately 130,000 gallons per year, with higher consumption rates during wet-weather periods. Deliveries are split between two locations: the DMF location with one 6,000-gallon tank and the Chlorine building location with two 6,000-gallon tanks. The supplier is required to budget additional time for split deliveries into their unit pricing and must utilize renewable fuel for delivery trucks.
The Off-Loading Authorization Form mandates comprehensive safety protocols across three phases: prior to off-loading, during off-loading, and after off-loading is complete. Critical requirements include barricade placement around the chemical receiving area, verification of proper personal protective equipment (PPE) for both driver and WQCP personnel, confirmation of chemical specifications and delivery documentation (Bill of Lading, Certificate of Analysis, and Weight Certificate), maintenance of a 10% safety margin in tank volume with a maximum tank volume of 5,000 gallons, continuous monitoring for leaks during the unloading process with an attendant remaining within 25 feet per DOT regulations, and proper lockout/tagout procedures upon completion. The form explicitly states that authorization to proceed is not possible if any question is answered as "NO" unless the Supervisor in charge provides written documentation that alternative safeguards have been implemented. Failure to comply with prescribed precautions may result in disciplinary action up to termination and suspension of the business relationship with the supplier.
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Text version
12.5% Sodium Hypochlorite (SH) Date
Receiving / Off-Loading Authorization Form
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
| 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 |
| 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
BEFORE�
gals� 1� 3� 4� Ft�
AFTER�
gals� Ft�
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 |
File details come from the government source that posted it. Updated .