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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: eF!,IE& Street Address: Date of Inspection: lease circle"Yes or No" for all questions belo . If a circled response is in Bold Red font,then describe e deficiency,who it was reported to,action td en to correct the problem and the expected date of repair. 1 monthly inspection documents shall be store on-site in the AST inspection binder. Item: Tank#:1 Tank#2 Tank#: Tank#: Visible leaks on tanks,tank seams,connections,fittings or Yes o Ye Yes No Yes No elves: Visible leaks on piping,piping seams,connections,finings, Yes o Yes o Yes No Yes No flanges,threaded connections pumps or valves: Evidence of oil leaks/spills on the ground or other urface: jyft Yes o Yes No Yes No Corrosion on tanks,supports,piping,mounts or vat s: Yes o Yes No Yes No Excessive settlement of structures: Yes o Yes No Yes No MalfunctioningEquipment(pumps,valves,dis ,etc.): Yes o Yes No Yes No lent hatch, pipes and s are missingor unsecured Yes a Yes No Yes No lectrical conduit or wires are exposed: Yes Yes No Yes No My sheen on the surface of any water located in th Yes o Yes No Yes No econ containment area(Verifybefore drainin eaves or other debris in the secondaryarea if so move): Yes o Yes No Yes No PA diamond,no smokin and contents stickers issin : Yes o Yes No Yes No Dis ensers/Fuel Islands Location Description: isible leaks on or around the dispensers, hoses, nozzles Yes and and surrounding area: isible fuel inside the sum /below an fuel dispenser: Yes CC eights and Measures certification ex fired if a licable : WAO - in Extinguishers—Serviced and tagged within the last ye No the yellow needle gauge is in the en zone: ill cean-up supplies are pmsern and well stacked: Ye o Deficiencies Noted: Action Taken: Especter!Date of Repair: All deficiencies Reported to: Date: Name of employee conducting the inspection Anted): Date: 013 ignature•