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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: eF- s& 11101111 F ON-SITE FURING Street Address: Date of Inspection: 12 -3 - 18 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#:I k#-L. Tank#: Tank#: Visible leaks on tanks,tank seams,connections, filings or Yes Yes Yes No Yes No elves' Visible leaks on piping,piping seams,connections,fittings, Yes o Yes® Yes No Yes No flanges,threaded connections pumps or valves: Evidence of oil leaks/spills on the ground or other surface: Yes Yes o Yes No Yes No Corrosion on tanks,supports,piping,mounts or valves: Yes Yes Yes No Yes No Excessive settlement of structures: Yes W Yes ®o Yes No Yes No Malfunctioning Equipment(pumps,valves,dispenser,etc.): Yes Yes Yes No Yes No Vent hatch, pipes and caps are missing or unsecured; Yes Yes o Yes No Yes No Electrical conduit or wires are exposed: I Yes(M) Yes Yes No Yes No Oily sheen on the surface of any water located in the Ye No a No Yes No Yes No secondary containment area(Verify before drainin . Leaves or other debris in the second area if so,remove : Yes o Yes Yes No Yes No FPA diamond,no smokingand contents stickers missin : es No a No Yes No Yes No Dis ensers/Fuel Islands Location Description: isible leaks on or around the dispensers, hoses, nozzles Yes 0o and and surrounding area: isible fuel inside the sum /below an fuel dis nser: YeSWI eights and Measures certification expired if applicable): Yes ire Extinguishers—Serviced and tagged within the last yeat r7a>No the yellow needle gauge is in the en zone: Sill clean-up supplies are present and well stocked„ es o Deficiencies Noted: Action Taken: Espotted Date of Repair: 12 All deficiencies Reported to: Date: n Name of employee conducting the inspection (Printed): Date: O ignature: