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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: E,Fv2.,L LLL Street Address: Date of Inspection: 'los S. \\0 1 O - l- \8 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. 1 monthly inspection documents shall be stored on-site in the AST Inspection binder. Item: Tank#: \ Tank#.L Tank#: Tank#: r leaks on tanks,tank seams,connections,fittings or Yea o Yes o Yes No Yes No leaks on piping,piping seams,connections, tttings, Yea oYes o Yes No Yes No threaded connections um s or valves: ce of oil leaks/s ills on the and or other surface: Yes Yes Yes No Yes No on on tanks,su oris, i in mounts or valves: Yes Yes o Yes No Yes No ve settlement of structures: Yes Yes Yes No Yes No ctionin ui ment( um s,valves,dis s r,etc. : Yes Yes Yes No Yes No tch pipes and caps are missingor unsecured:— Yes Yes o Yes No Yes No Electrical conduit or wires are exposed: Yes o Yes Yes No Yes No Oily sheen on the surface of any water located in thYes Yea o Yea No Yes No secondary containment area(Verify before drainin : Leaves or other debris in the second area if so ove : Yes Yes Yes No YesNo PA diamond, no smokingand contents stickers missing: Yea Yes o Yes No Yes No Dis ensers/Fuel Islands Location Description: Visible leaks on or around the dispensers, hoses, nozzles a No may.-t\p iA \ ground and surrounding area: Visible fuel inside the sum /below my fuel dispenser: Yes Weights and Measures certification expired if applicable): Yes Fire Extinguishers—Serviced and tagged within the last ye ®e No the yellow needle gauge is in the green zone: Spill clew-up supplies are present and well stocked: a No Deficiencies Noted: Action Taken: Ez ected Date of Repair: \U -S- All deficiencies Reported to: Date: -x% 71 Name of employee conductina the inspection(Printed): Date: t Cz -\-\ mature•