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AST & DISPENSER MONTHLY INSPECTION FORM �. Facility Name: eFu`M. Street Address: Date of Inspection: o S.VAsc c o 5- 3 - 18 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. 11 monthly inspection documents shall be sto d on-site in the AST Inspection binder. Item: Tank#: Tank#: Tank#: Tank#: Visible leaks on tm*s,tank seams,connections,fi gs or Yes©o Yes Yes No Yes No valves: Visible leaks on piping,piping seams,connections, tttings, Yes o Yes4U Yes No Yes No flanges,threaded connections um s or valves: Evidence of oil leaks/spills on the and or other urface: Yea Yes Yes No Yea No Corrosion on tanks, supports,piping,mounts or vaI es: Yes Yes Yes No Yes No Excessive settlement of structures: Yes Yes Yes No Yes No Malfunctioning Equipment( um s,valves,dispenser,etc.): VesCSO Yes MoN Yes No Yes No Vent hatch,pipes and ens are missing or unsecured: Yes"& Yiss Yes No Yes No Electrical conduit or wires are exposed: YesYes No Yes No �. Oily sheen on the surface of any water located in the Yes Yes No Yes No secondary containment area(Verify before draining): Leaves or other debris in the second area if so, remove : Yes Yes o Yes No Yes No PA diamond,no smoking and contents slickers missin : Yes o Yes o Yes No Yes No Dis ensers/Fuel Islands Location Description: isible leaks on or around the dispensers, hoses, nozzles Yes o and and surrounding area: isible fuel inside the sum /below an fuel dispenser: Yes o eights and Measures certification expired if a licable : Yes No ire Extinguishers—Serviced and tagged within the last ye Yes No the yellow needle gauge is in the en zone: S ill clean-up supplies are present and well stocked: 7—CS5 No Deficiencies Noted: Action Taken: Ex ected Date of Repair: All deficiencies Reported to: Date: Name of employee conducting the inspection (Printed): Date: ignature: