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AST & DISPENSER MC INTHLY INSPECTION FORM Facility Name: &RUES. MOBILE ON-SITE FUR ING Street Address: Date of Inspection: I -2- I r circle "Yes or No" for all questions belo . If a circled response is in Bold Red font, then describficiency,who it was reported to, action en to correct the problem and the expected date of repair. nthl inspection documents shall be stored on-site in the AST Inspection binder. Item: Tank#: I Tank#: Tank#: Tank M isible leaks on tanks,tank seams,connections,fittings or Yes®o Yes Yes No Yes No elves: isible leaks on piping,piping seams,connections,fittings, Yes Co Yes o Yes No Yes No an es threaded connections puraps or valves: vidence of oil leaks/spills on the ground or other surface: Yes Yes Yes No Yes No orrosion on tanks,supports,piping,mounts or valves: Yes Yes Yes No Yes No xcessive settlement of structures: Yes 1Ye. Yes No Yes No alfunctionin Equipment(pumps,valves,dispenser,etc.): Yes o Yes No Yes No ent hatch i s and ca s are missin or unsecured: , Yes o Yes No Yes No lectrical conduit or wires are ex sed: Yes Yes No Yes No ily sheen on the surface of any water located in the! Yes oYes No Yes No and containment area(Verifybefore draining): eaves or other debris in the second area if so remove : Yes Yes o Yes No Yes No FPA diamond,no smoking and contents stickers missing: Yes Yes o Yes No Yes No Dis ensers/Fuel Islands Location Description: isible leaks on or around the dispensers, hoses, nomles Yes 19 round and surrounding area: isible fuel inside the sum /below an fuel dispenser: Yes o eights and Measures certification ex fired if a licable : Yes VZ I ire Extinguishers—Serviced and tagged within the last y o the yellow needle gauge is in the en wne: ill clean-up supplies are resent and well stocked: a No Deficiencies Noted: Action Taken: Ex ected Date of Repair: All deficiencies Reported to: Date: Name of employee conducting the inspection(Printed): Date: O igtature: