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AST & DISPENSER MC NTHLY INSPECTION FORM �.. Facility Name: � /CE e, . 00& MOBILE ON-51LE FUELING Street Address: Date of Inspection: Please 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. ll monthly ins tion documents shall be stor on-site in the AST Inspection binder. Item: Tank#: 1 Tank#:2Tank#: Tank#: Visible leaks on tanks,tank seams,connections,fitti gs or Yes Yes Yes No Yes No elves: Visible leaks on piping,piping seams,connections,f kings, Yes o Yea Yes No Yes No flanges,threaded connections,pumps or valves: Evidence of oil leaks/spills on the ground or others ace: Yes Yes Yes No Yes No Corrosion on tanks,supports,piping,mounts or vale s: Yes Yes Yes No Yes No Excessive settlement of structures: Yes o Yes o Yes No Yes No Malfunctioning Equipment(pumps,valves,dispense ,etc.): Yes Yes Yes No Yes No fent hatch pipes and caps are missingor unsecured: Yes Yes Yes No Yes No lectrical conduit or wires are exposed: Yes Yes Yes No Yes No ^ My sheen on the surface of any water located in the Yes t® Yes Yes No Yes No econ containment area(Verifybefore draining): eaves or other debris in the secondary area if so, remove): Yes o Yes Yes No I Yes No FPA diamond no smoking and contents stickers missing: Yes W_c,31 Yes CDo Yes No Yes No Dis ensers/Fuel Islands Location Descri tion: isible leaks on or around the dispensers, hoses, nozzles Yes ound and surrounding area: isible fuel inside the sum /below un fuel dispenser: Yes eights and Measures certification expired if a licable : Yes ire Extinguishers—Serviced and tagged within the last ye a No the yellow needle gauge is in the green zone: ill clew-up supplies are present and well stocked: Ye No Deficiencies Noted: Action Taken: Ex ected Date of Re air: All deficiencies Reported to: Date: �. Name of employee conducting the inspection (Printed): Date: ignature: