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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: eF�`:. MORILF ON-SITE FUD ING Street Address: Date of Inspection: z - q -r Please circle "Yes or Nd'for all questions below. If a circled response is in Bold Red font, then describe e deficiency, who it was reported to,action talen to correct the problem and the expected date of repair. I monthly inspection documents shall be stated on-site in the AST Inspection binder. Item: Tank#: I Tank#:Z.Tank#: Tank M Visible leaks on tanks,tank seams,connections,fittings or Yes �o Yes® Yes No Yes No elves: Visible leaks on piping,piping seams,connections, fittings, Yes M> Yes M> Yes No Yes No flanges,threaded connections pumps or valves: Evidence of oil leaks/spills on the ground or other surface: Yes Yes Ob Yes No Yes No Corrosion on tanks,supports,piping,mounts or valves: Yes no Yes Yes No Yes No Excessive settlement of structures: Yes to) Yes Yes No Yes No Malfunctioning Equipment um s,valves,itis n ,etc. : Yes Q Yes Yes No Yes No ent hatch pipes and caps are missingor unset Yes Yes Yes No Yes No Electrical conduit or wires are exposed: I Yes o Yes Yes No Yes No Oily sheen on the surface of any water located in the Yes o Yes o Yes No Yes No con containment area(Verifybefore draining): eves or other debris in the second area if so,remove): Yes Yes Yes No Yes No FPA diamond,no smokingand contents stickers missing: Yes o Yes Yes No Yes No Dis erasers/Fuel Islands Location Description: Visible leaks on or around the dispensers, boles, nozzles Yes round and surrounding area: Visible fuel inside the sum /below my fuel dis Yes Weights and Measures certification expired if a livable : Yes o Fire Extinguishers—Serviced and tagged within the last ye No the yellow needle gauge is in the green zone: Spill clean-up supplies are present and well stocked: a No Deficiencies Noted: Action Taken: Ex ected Date of Repair: Ali deficiencies Reported to: Date: Name of employee conducting the inspection Trinted): Date: ignature: O