COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

AST & DISPENSER MONTHLY INSPECTION FORM Facility Name: V,)EAM E;'— `C -,)CX-r—Mcg j if—mig J o& Street Address: ate of Inspection: -1 --L Z Loc q - a 10 Please circle "Yes or No" for all questions below. If a circled response is in Bold Red font, then describe he 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: S Hyp sHCb Tank#: Tank#: Tank#: Tank#:2 isible leaks on tanks,tank seams,connections,fittings or Yes o Yes No Yes o Yes alves: QD Visible leaks on piping,piping seams,connections,fittings, Yes o Yes No —Ye—se— YesNo flanges,threaded connections, pumps or valves: vidence of oil leaks/spills on the ground or other surface: ___Y_esf on Yes No e NoYes o Corrosion on tanks, supports,piping,mounts or valves: Yes(N- OD Yes No es o Yes o Excessive settlement of structures: Yes 'o Yes No Yes o Yes No alfunctioning Equipment(pumps,valves, dispenser,etc.): Yes o Yes No Yes o Yes N Vent hatch, pipes and caps are missingor unsecured: Yes Yes No Yes Yes o Electrical conduit or wires are exposed: Yes Yes No Yes o Yes No Oily sheen on the surface of any water located in the es No Yes No Yes o YesNo' second containment area(Verifybefore draining eaves or other debris in the secondary area(if so, remove): Yes o Yes No YesKo Yes PA diamond,no smokin and contents stickers missing: e No Yes No YesYe llis ensers/Fuel Islands Location Description isible leaks on or around the dispensers, hoses, nozzles Yes ound and surrounding area: ED Visible fuel inside the sum /below any fuel dispenser: Yes o 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 geen zone: Spill clean-up supplies are present and well stocked: Ye No Deficiencies Noted: Action Taken: Expected Date of Repair: All deficiencies Reported to: Date: F L I Name of employee conducting the inspection (Printed): Date: Signature•