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AST & DISPENSER M NTHLY INSPECTION FORM Facility Name: eFIRUEL Street Address: Date of Inspection: 3 -'i- l 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. 1 month) tion documents shall be stored on-site in the AST Inspection binder. Item: Tank#: I Tank#:Z Tank#: Tank#: isible leaks on tanks,tank seams,connections,fi ' gs or Yes � Yes IQ Yes No Yes No alves: isible leaks on piping,piping seams,connections,fittings, Yes Yes Yes No Yes No an es threaded connections pumps or valves: vidence of oil leaks/spills on the and or other urfsce: Yes Yes Yes No Yes No orrosion on tanks,supports,piping,mounts or val s: Yes Yes o Yes No Yes No xcessive settlement of structures: Yes o Yes Yes No Yes No alfunctioning Equipment(pumps,valves,dis n ,etc.): Yes Yes o Yes No Yes No Vent hatch pipes and caps are missingor unsecured Yes Yes Yes No Yes No Electrical conduit or wires are exposed: Yes Yes o Yes No Yes No Oily sheen on the surface of any water located in th Yea o Yes Yes No Yes No secondary containment area(Verify before draining): Leaves or other debris in the second area if so remove): Yes Tv Yes Yes No Yes No FPA diamond,no smokin and contents slickers missin : Yes o Yes Yes No Yes No Dis ensers/Fuel Islands Location Description: Visible leaks on or around the dispensers, hoses, nozzles Yea o round 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 a No the yellow needle gauge is in the green zone: Spill clean-up supplies are present and well stocked: No Deficiencies Noted: Action Taken: Ex ected Date of Repair: Ali deficiencies Reported to: Date: Name of employee conducting the inspection (Printed): Date: 1 3 -K - [Ci [S-491amt�uc-