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AST & DISPENSER MQNTHLY INSPECTION FORM TlFacility Name: OUR Street Address: Date of Inspection: OSS - ,l - 20 lease circle "Yes or No"for all questions below. If a circled response is in Bold Red font, then describe e deficiency, who it was reported to, action taken to correct the problem and the expected date of repair. 11 monthly inspection documents shall be stored on-site in the AST Inspection binder. Item: Tank* I ank#:2 Tank#: Tank#: Visible leaks on tanks,tank seams,connections,Ind gs or Yeso yes(ZD Yes No Yes No elves: Visible leaks on piping,piping seams,connections,fittings, Yes oI Yes Yes No Yes No flanges,threaded connections um s or valves: Evidence of oil leaks/spills on the ground or other urface: Yes Yes Yes No Yes No Corrosion on tanks,supports,piping,mounts or valves: Yes Yes Yes No Yes No Excessive settlement of structures: I Yes Yes Yes No Yes No Malfunctioning Equipment(pum s,valves,dispenst r,etc.): Yes o An Yes No Yes No Vent hatch pipes and caps are missingor unsecured Yes o Yes No Yes No Electrical conduit or wires are exposed: Yes Yes No Yes No Oily sheen on the surface of any water located in theYes a Yes No Yes No secondary containment area(Verify before drain in : Leaves or other debris in the second area if so move): I Yes o Yea o YesNo Yes No FPA diamond,no smokingand contents stickers issin : Y o Yes Yes No Yes No Dis ensers/Fuel Islands Location Description: Visible leaks on or around the dispensers, hoses,',nomles es No Np-LZ,\S LEP. -v�M ground and surrounding area: oN PV isible fuel inside the sum /below any fuel dispenser: es Weights and Measures certification expired if applicable): Yes Fire Extinguishers—Serviced and tagged within the last ye ®No the yellow needle gauge is in the green zone: Spill clean-upsupplies are resent and well stocked: a No Deficiencies Noted: Action Taken: Expeected Date of Repair: All deficiencies Reported to: Date: Name of employee conducting the inspection (Printed): Date: igttature: