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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: eF�`AL MOBILE ObLSITTEUELING Street Address: Date of Inspection: 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 stored on-site in the AST Inspection binder. Item: Tank#: Tank#: Tank#: Tank#: Visible leaks on tanks,tank seams,connections,fittirigs or Yes t o Yes Yes No Yes No valves: Visible leaks on piping,piping seams,connections,fittings, Ye Yes Yes No Yes No flanges,threaded connections PUMPS or valves: Evidence of oil leaks/spills on the ground or other surface: Yes Yes o Yes No Yes No Corrosion on tanks, supports,piping,mounts or valves: Yes Yes(So) Yes No Yes No Excessive settlement of structures: Yes Yes o Yes No Yes No Malfunctioning Equipment(pumps,valves,dispenser,etc.): Yes o Yes Yes No Yes No lent hatch,pipes and caps are missing or unsecured: Yes Yeso Yes No Yes No lectrical conduit or wires are exposed: Yes Yes Yes No Yes No ily sheen on the surface of any water located in th Yes I o Yes Yes No Yes No econdary containment area(Verify before draining : aves or other debris in the second area if so remove): Yes Yes Yes No Yes No FPA diamond,no smoking and contents stickers n issirac Yes 007 Y—Way Yes No Dis ensers/Fuel Islands Location Description: Visible leaks on or around the dispensers, hoses,!nonles Yes ground and surrounding area: Visible fuel inside the sum /below my fuel dispen er. Yes Weights and Measures certification expired if a licable : Yes o Fire Extinguishers—Serviced and tagged within the last yew No the yellow needle gauge is in the grecu zone: Spill clema-up supplies are present and well stocked Y No Deficiencies Noted: Action Taken: Ex ected Date of Repair: All deficiencies Reported to: Date: Name of employee conducting the inspection(Printed): Date: ignature _ _1$