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AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: '.. eF!liffS. MQRILF ON-SITE FUELING 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. I 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,fitti gs or Yes(Eo) Yes n Yes No Yes No elves: Visible leaks on piping,piping seams,connections, ttings, Yeso Yes o Yes No Yes No flanges,threaded connection pumps or valves: Evidence of oil leaks/spills on the ground or other a zfface: Yes YesMo Yes No Yes No Corrosion on tanks,supports,piping,mounts or valves: Yes Yes1--,. Yes No Yea No Excessive settlement of structures: Yes o YesYes No Yes No alfunctioning Equipment(pum s,valves,dispenser,etc.): Yes o Yes Yes No Yes No ent hatch i s and ca s are missin or unsecured: Yes o YesYea No Yes Nlectrical conduit or wives are ex sed: Yes o Yes Yes No Yes No ily sheen on the surface of any water located in the Yes o Yes Yes No Yes No secondary containment area(Verify before draining): Leaves or other debris in the second area if so move : Y Yes Yes No Yea No FPA diamond, no smoking and contents stickers m ssin : I YeskNo Ye Yes No Yes No Die ensers/Fuel Islands i 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 ei is and Measures certification expired if a licable : Yes o ire Extinguishers—Serviced and tagged within the last ye No the yellow needle gauge is in the en zone: Sill clean-up supplies are present and well stacked: a No Deficiencies Noted: Action Taken: Expected Date of Repair: AB deficiencies Reported to: Date: �. Name of employee conducting the inspection(Printed): Date: ignature: