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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: Iffy Street Address: Date of Inspection: 5-1ICI - lease circle "Yes or No"for all questions below. If a circled response is in Bold Red font,then describ e deficiency,who it was reported to,action taken to correct the problem and the expected date of repair. 11 monthly ins 'on 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 Y o Yes o Yes No Yes No elves: isible leaks on piping,piping seams,connections,fittings, YesS) Y.Q.) Yes No Yes No hinges,threaded connections,pumps or valves: vidence of oil leaks/spills on the ground or other surface: Yes o Yeso on Yes No Yes No orrosion on tanks,supports,piping,mounts or valves: Yes o Yes o Yes No Yes No xcessive settlement of structures: Yes o Ye, o Yes No Yea No alfunctioning Equipment(pumps,valves,dis a ,etc.): Yes Ye o Yes No Yes No tent hatchpipesend sere missing or unsecured Y o Ye Yes No Yes No Electrical conduit or wires are exposed: Yes o Yes o Yes No Yes No Oily sheen on the surface of any water located in the Yes o Ye o Yes No Yes No con containment area(Verify before draining): L,eaves or other debris in the second area if so,remove : Ye o Ye Yes No Yes No FPA diamond no smokingand contents stickers missing: e o e No Yes No Yes No Dia ensers/Fuel Islands Location Description: Visible leaks on or around the dispensers, hoses, nozzles V ground and surrounding area: Visible fuel inside the sum /below my fuel dispenser: Yes Weights and Measures certification expired if applicable): Yes o Fire Extinguishers—Serviced and tagged within the last ye No the yellow needle gauge is in the green zone: Spill clew-up supplies are present and well stocked: a No Deficiencies Noted: Action Taken: Ex ected Date of Repair: All deficiencies Reported to: Date: !1 Name of employee conducting the inspection (Printed): Date: kgn't,