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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: eIffff FWS& Street Address: Date of Inspection: 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. 11 monthly inspection documents shall be sto on-site in the AST Inspection binder. Item: Tank#: Tank#: Tank#: Tank#: Visible leaks on tanks,tank seams,connections,fittings or YeNQ3o Yes Yes No Yes No elves: Visible leaks on piping,piping seams,connections,fittings, Yes® Yes(r2) Yes No Yes No flanges,threaded connections pumps or valves: Evidence of oil leaks/spills on the ground or other surface: Yes o Yes o Yes No Yes No Corrosion on tanks,supports,piping,mounts or valves: Yes o Yea o Yea No Yes No Excessive settlement of structures: Yes Yes Yea No Yes No elf inctioning Equipment(pumps,valves,dis n ,etc.): Yes o Yes Yes No Yes No Vent hatch,pipes and cans are missin or unescorted: Yes o Yes Yes No Yes No Electrical conduit or wires are ex sed: Yes Yes Yes No Yes No Oily sheen on the surface of any water located in the Yes Yes o Yes No Yes No con containment area(Verifybefore draining): Leaves or other debris in the second area if so,remove): Yes Yes Yea No Yes No FPA diamond,no smokingand contents stickers missing: Yes Yes o Yes No Yes No Dis ensen/Fuel Islands Location Description: isible leaks on or around the dispensers, hoses, nozzles Yeso ound and surrounding area: isible fuel inside the sum /below my fuel dispenser: Yes eights and Measures certification expired if a licable : Yes o ire Extinguishers—Serviced and tagged within the last ye a No the yellow needle gauge is in the en zone: ill clean-upsupplies are resent and well stocked: No Deficiencies Noted: Action Taken: Ex ected Date of Repair: All deficiencies Reported to: Date: !1 Name of employee conducting the inspection (Printed): Date: y-i- tq igoature•