120488 O3 ADD THREE-REVISED ATTACHMENT B (1).docx.pdf

SPB Form 28 Effective 7-19-2024

SOLICITATION ADDENDUM 120488 O3

REVISED ATTACHMENT B

Date: March 25, 2025

To: All Bidders

From: Sam Franklin/Christie Kelly, Nebraska Department of Correctional Services (NDCS)

RE: Addendum for 120488 O3 to be opened April 4, 2025, at 2:00 p.m. CST

Revised Attachment B

Revised Attachment B to include Annual Fie Sprinkler Inspection Report for Nebraska State Penitentiary (NSP).

This addendum will be incorporated into the solicitation.

NDCS ATTACHMENT B. ANNUAL FIRE SPRINKLER INSPECTION

REPORTS

LOCATION OF SYSTEM:

f"i'NEBRASKA STATE FIRE MARSH~~ ' .FrlRE SPRINKLER INSPECTION • ..

. n

INITIAL ACCEPTANCE OF SYSTEM

ABOVEGROUND TEST CERTIFICATION (FORM 85-AC) REINSPECTION DUE TO REMODEL, REPAIR, ETC

REPORT OF INSPECTION PERIODIC ANNUAL INSPECTION

ORY PIPE VALVE TEST BACKFLOW PREVENTER TEST

ITEM # DIRECTORY DEFICIENCIES

1 - WET RISER

2- DRY RISER

5 - BACKFLOW PREVENTER ITEMIZE DEFICIENCIES NOTED ON INSPECTION AND

~ = gl~~~PI PE ANY OTHER PERTINENT COMMENTS ON SYSTEM 3 - PREACTION RISER

4- FIRE PUMP

TAG# ITEM# MAJOR DEFICIENCIES/ COMMENTS

COMPANY PERFORMING INSPECTION:

I

MAHONEY /<·i·,1:1~~::;.

Fire Sprinkler, Inc. i\j{?\ NE LICENSE#: 18021 • t--:T==e=-=s=-=T=e=R-=e=F=P-=-L=,c~E~N~S~E~#:~. ~r,-,-,"¥-------

1111 5 'O ' Street • Omaha, NE 68137

(402).-553-1 221 • (402) 553-4545 FAX OWNER REPRESENTATIVE SIGNATURE

SEND TO: NEBRASKA STATE FIRE MARSHAL- 246 SOUTH-14TH ST-1LINCOLN, NE 68608-1804

A COPY OF THIS INSPECTION REPORT SHALL BE LEFT ATTACHED TO THE SYSTEM RISER

REPORT OF INSPECTION

PAGE 1 OF2

11115 'O'Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

REPORT TO ._~C~G"--'-C~---1.C,,,,_) ___ ~----..,----O------~---- DATE_,_____-'----'-----"-~~-.:____:_..:.._:

ADDRESS ___ ~J~1~J.~6 _ ___.f{..<---~&...,_._; V:_z~_S-=----~c~·~« '--1 (Y-~~Pr ____ TECHNICIAN--J~-'7'-+--:~'-----

Owners Section (To be answered by owner or occupant) A. Describe any fire protection modifications or occupancy hazard changes since previous inspection._-====-----~=::.....::======--------=::_ _ _i::~..,

1. GENERAL

a. Is the building occupied? :::.t------,

b. Are all systems in service? ••••1-----

c. Is there a minimum of 18 in. (457mm) clearance between the top ol lhe storage and the sprinkler deflector? •::::.•,.._ ___ _

d. In areas protected by wet system, does the building appear to be properly heated in all areas. including blind attics ::::::

and perimeter areas. where accessible? Do all exterior openings appear to be prolected against freezing? ••••••1-----e, Does the hand hose on the sprinkler system appear to be satisfactory? -----------------='--'::::::=='----4-----1-3'.. __ -1--= ~

2. CONTROL VALVES (See Item 14) •·••·

a. Are all sprinkler system control valves and all other valves ,n the appropriate open or closed position?

b. Are all control valves In the open position and locked . sealed or equipped with a tamper switch?

3. WATER SUPPLIES (See Item 15)

a. Was a water flow test of main drain made at the sprinkler riser? -~ ~=~=~____::::'.:.:...c::.::..::::..C:~~~:!:J~"'--=~:.C:C.-...+-4 ---l

4. TANKS, PUMPS, FIRE DEPARTMENT CONNECTIONS

a. Are fire pumps, gravity tanks, reservoirs and pressure tanks on good condition and

b. Are fire department connections in satisfactory condition . couplings free . caps in

Are they accessible and visible? -----·--------------------------====-- +-...c.;_-+.a....-..-.....t---==-.::....._:_

5. WET SYSTEMS (See Item 13) a.

b. Have antifreeze system solutions been tested? - ------------~~;S:~~~~_:,~"i=-.'.::--::::'::~~f--t--t?'-+-.......:.--+--:ik5

c. Were the antifreeze test results satisfactory?

6. DRY SYSTEMS (See Items 10 to 14)

a. Is the dry valve in service?

b. Are the air pressure and pro m1ng water level In accordance wi c . Has the operation of the aor or nitrogen supply been tested' I

d. Were low points drained during this inspection?

e, Did quick-opening devices operate satisfactorily? ____ .....c;:..::c...~c=c.:~~~'.:::.:=-~~~~~~=-~ =--__:_:::_:~ :.__-~---=~ -+---l,------+----=== = "l f . Did the dry valve trip properly during the trip pressure test?

g. Did the heating equipment in the dry-pipe valve room operate at the lime of 1nspecfion? ----::;::::;-- ==-=:;;:::=;:====-- + - ~ --+--f- --jf--:~~

7. SPECIAL SYSTEMS (See Item 16)

a. Did the deluge or pre-action valves operate properly during testing?

b. Did the heat-responsive devices operate properly during testing?

c . Did the supervisory devices operate during testing?

8. ALARMS

a. Did water motor and gong test satisfactorily?

b. Did electric alarm test satisfactorily? ----- ~~~8'=~~==;;;-~~~~~~-;;;;.~~~~~~~~~~- -+_:~ --+--;:::=--f--~~=:'

c. Did supervisory alarm service test satisfactorily?

9. SPRINKLERS

a. Are all sprinklers free from corrosion. loading or obstruction to spray discharge? -=-- ---=;..:...,~ ----==--== '----l-~ l,-,--le9

b. Are all sprinklers less than 50 years old, including quick response less than 20 years old? --------=-- -=-='------+----,!--,---4•••

c. Is stock of spare sprinklers available? ~~;;;;-;;~~;;;-;~-;;;;~;;--:::===:=:~s~~~~~~~~~~=t=t=r.:::i=1~~ d. Does tti_e exterior condition of sprinkler system appear to be satisfactory? ~--_,..,.-

Are sprinklers ol proper temperature ratings for their locations?

• faplain "No" Answers on Page 2 tNot applir.able

PAGE 2 OF 2 MAHONEY

Fire Sprin

11115 'O' Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

REPORT TO -~C-_c~c-__ f)~----- ----------- DATE _____.7..____- ..;_1_1_-___;_(2-4'.y _____ _ _

Wet Systems No: Make and Model :

Dry Systems No: Make and Model:

Special Systems No:

Condition?

10. Date dry pipe valve trip tested (control valve partially open)

11. Date dry pipe valve trip tested (control valve fully open)

12. Date quick opening device tested

13. Date deluge or prea.ction valve tested

14.

Control Valves Number

Control Valve Maintenance Table

See Trip Test Report See Trip Test Report See Trip Test Report See Trip Test Report

Closed Signs Explain Abnormal Condition

City Connection Control Va,..lv_e _ __ -+--L-'--"--l-- --'"---+----'__._ _ __,f------+--- -+---------------...:_...:....;:__:._ Tank Control Valves

Pump Control Valves Sectional Control Valves

System Control Valves Other Control Valves

15.

Water Pressure? City / 7 0 ----

PSI Tank ____ PSI

Water Flow Tes_t?_. -----➔~'f-";{_',J _____ (If none made. Why?)

Flow

WATER FLOW TEST

Test Pipe Located

Test Pipe Size

Pressure Berore

Flow Pressure

Pressure After

16. 5 Year IPI, Gauges, FDC Check Valve, CommeJlJ

a. When was the system installed. ---JL~C/--=K;_!._--.::,;-=----- _.::._---,--=--=---=:::::;:...:=.-...;....:,,,...,~ =-~c---:~ ..:....----- -=__::=-=-- ~ =---=:........:::...:

b. When was the Last 5 year do-ne_.~~;:::':A::tJ,:~t;?J!JJit-~::J}fiJ:J:::ii'iJ:jfJ;~~~;[~~:;;;;;;;;.~:;;~:;:~ffJ[;iJ];~~;_~;;:::J, c. When is the Next 5 year due. cfl.-'1!._2-, 5

d. Comments_-::;-- ::;-- - ---:::--- --=-=--"----- ----"'~-=--'-;:::::"-:::::::;- =.c==~===;:::;;:=-===-:;=::---- ---=::--=-- -";:;=-= ;--'"'-- --:--'C::

17. Explain any "No" answers and comments:

I I

I 18a. Is the fire sprinkler system monitored by 24 HA monitoring? ~es O No

18b. This fire sprinkler system is required to have 24 HR monitoring . Failure to monitor the fire sprinkler system can ultimately lead to substantial loss.

Initial here to acknowledge:

19. Although these comments are not the result of an engineering review. the following desirable improvements are recommended:

PaQe 2 of 2

- i

JL Backflow Device Test Report .

402.504.7807 • e-mail: backflow@mudnebr.com • website: www.mudomaha.com

METROPOLITAN

UTILITIES DISTR IC T Return to: Metropolitan Utilities District, 7350 World Communications Dr., Omaha, NE 68122

Name.:

Bus/Owner: )?C Test completed

Address: □ Test failed

Account No. JU □ Retest after repair

I JI Annual Test □Relocate □Replacement □ New Installation

Old serial #: • ------------ Location:

Contact person:

Repair information: ~~~~~~~~--~:b~~~~ fit I

' Reduced Pressure - Double Check Valve I Pressure Vacuum Breaker

Relief valve (RP only) opened at ____ PSID

Check valve # 1 :Z. • J PSID Held al yes O no

I Shut off #2 Held □ yes □ no I

Check valve #2 ~ . _j__ PSID Held Cl! yes □ no j Shut off #I Held □ yes □ no

[ Check valve □ Held at ---==-" __ PSID

Shut off #2 .-. Held ~ yes Ono

Air vent opened at_. __ PSID

Prevents backflow from:

□ Carbonator □ Water cooled compressor □ Photo developer or x-ray □ Humidifier

□ Lawn sprinkler □ Food processing □ Boiler makeup El Cooling tower •

□ Dry cleaning □ Mortuary □ Laboratory or hospital □ Vacuum pump

□ Fountain □ Swimming pool □ Chemicals Service containment

~ Other (describe): Fire Sgrinkler S~stem - I hereby ccrt il)' the above backtlO\\ preventer has been tested in accordance with all rules and n:gulations of the State of Nebraska I kalth and I luman Services, Department of Regulation an<l Licensure. Titk 179. and the ~'1etropolitan Utili ties District , and that all reading are true and accurate to the best of my knowledge.

Date of test

Employer of state certified technician Mahoney Fire Sprinkler, Inc. Phone: 402-553-1221 Fax: 402-553-4545

IN /JJ;, -f - t)•' l./r1J-J ,:;-- Ljl , Test gauge manufacturer /ll1Q{J/j?>: Test gauge serial # ___ Date calibration verified 5...21/.- 1\ccuracy verified by III. Inc.

I 61~ (Ol,30211tk I j__ Backflow Device Test Report

402.504.7807 • e-mail: backflow@mudnebr.com • website: www.mudomaha.com

METROPOLITAN

UTILITIES DISTR IC T Return to: Metropolitan Utilities District, 7350 World Communications Dr., Omaha, NE 68122

Name: CCC r)

Bus/Owner: ;( / ~ Test completed

Address: ~ 3J-~ (Z_ /lrl-1, ~ □ Test failed

Account No. rfvvz ~ lt ~ Ji_, (}1 fl; I () □ Retest after repair r------~-~ ------= y{ Annual Test ' □Relocate □Replacement

Old serial #:

Manufacturer: _ _,t~Wi~' +--f/J-i+-<'-------

Location:

Model: tf () 1 IJ1 :2 Serial #: /) IO S'J,, I

Device type: ...:::......:._-1--g--=-p- --=-~'----

Con tact person: '.:::'....:== ..... =.~=,....~ _,,,= _==--==.:::_:____::_.:._:..........,~

Repair information: ~ ~~~ ~ ~ ~~~~~~

Size:

' Pressure Vacuum Breaker Reduced Pressure - Double Check Valve

Relief valve (RP only) opened at f . 2.. PSID

Check valve # 1 _(1f_, ;J PSID Held ~ yes □ no

Shut off #2

Shut off # I

Held

Held

0 yes □ no

□ yes □ no

Check valve #2

Shut off #2

;L • !}__ PSID Held ~ yes □ no Check valve □ Held at

Held , li2f' ves ,fi I r J

□-no_ j Air vent opened at ___ ~ ..

PSID --

PSID

"""' Prevents backflow from: • / ,..

□ Carbonator □ Water cooled compressor □ Photo developer or x-ray □ Humidifier

□ Lawn sprinkler • El Food processing □ Boiler makeup □ Cooling tower • ~

□ Dry cleaning □ Mortuary □ Laboratory or hospital □ Vacuum pump

□ Fountain □ Swimming pool

□ Chemicals □ Service containment #

~ Other (describe): • L Fire SQrinkler System <"'

I hereby certify the nbove backflow preventer has been tested in accordnnce with all rules and rcgulntions of the State ofNcbrnska l lcalth nnd I luman Services, Department of Regulntion and Licensure. Title 179, and the Metropolitan Utilities District. nnd that all reading arc true and accurate to the best of my knowledge.

Stnte certified technician (signature) Customer (signat:irc) :( - -..___,;;_ -+----==---fr---½=..-""---=-::::------ / ,._L\---y-- --.,;;:;;~;;;:::;;::;:;;;:----;;;;::;;;;;;;::~

Employer or stnte certified technician Mahoney Fire Sprinkler, Inc. .., Phone: 402-553-1221 Fax: 402-553-4545

Test gauge manufacturer ,~/1./!tJ{- Test gauge serial # tf'/!

J-.,J 1 ~ calibration verified ~/ Accuracy vcritkd by Ill , Inc.

lh2~ t0630~1hkl

...... r

NEBRASKA STATE FIRE MARSHAL

FIRE SPRINKLER INSPECTION

LOCATION OF SYSTEM: "I· 3. z.(f.

FORMS INCLUDED WITH THIS COVER SHEET

UNDERGROUND TEST CERTIACATION (FORM 85-AB)

ABOVEGROUND TEST CERTIFICATION (FORM 85-AC)

I REPORT OF INSPECTION

/ DRY PIPE VALVE TEST

ITEM # DIRECTORY

INSPECTION DA TE

TYPE OCCUPANCY

TYPE OF INSPECTION

INITIAL ACCEPTANCE OF SYSTEM

REINSPECTION DUE TO REMODEL, REPAIR, ETC

PERIODIC ANNUAL INSPECTION

BACKFLOW PREVENTER TEST

DEFICIENCIES

1 -WET RISER

2- DRY RISER

5 - BACKFLOW PREVENTER ITEMIZE DEFICIENCIES NOTED ON INSPECTION AND

~ = ~i~~PIPE ANY OTHER PERTINENT COMMENTS ON SYSTEM 3 - PREACTION RISER

4 - FIRE PUMP

TAG# ITEM# MAJOR DEFICIENCIES,' COMMENTS

I z.

s

11115 'O'Strcet • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

NE LICENSE#: 18021

TESTER BFP LICENSE #: f/ '13

OWNER REPRESENTATIVE SIGNATURE

SEND TO: NEBRASKA STATE FIRE MARSHAL- 248 SOUTH 14Tli ST- LINCOLN, NE 88!08-18°'

MAHONEY

Fire Sprinkler, Inc.

llll5'0'Street • Omaha,NE68137

(402) 553-1221 • (402) 553-4545 FAX

REPORT OF INSPECTION

REPORT m &rnmu, oi ~ urrtrJtooal Ceo fer DATE f•jf•z.4

ADDRESS 2 J '2.0 W. "'10 Dor ti 5 f Lin e,9/"" .• f'J6, <d:5:Z. Z. TECHNICIAN _&i,_.._,,,,...L _______ _

Ovmen, Section fTo be enewered by owner or occupent) A. Describe any tire protection modlficellons or occupancy "8zard changes ~r.ce previous Inspection. ________________________ _

B. wt.-.-lhelasl Syae,-di::IM? _2=-0=--===--='--------------------------------------ln1PKIOr'1 S1tellon IA!! responses ielerence current nspec!lon) I

GENERAL Yes N.A:t No"

II Is 1he !>u,lding occupied?

u·u=il b Are all systems ,n se,v,ce'

C Is there a m,n,mum of 18 ,n (457mm) clnrance between the top 01 lhe s!orage arid !he sprinkler deflector' -... -d In areu protected by wet system. does 1he bu,ld lng appear 10 be p1operly heated In all areas. including bl!nd attics •·:··=-•: .. and perimeter areas. where accessible? Do all exler,or openings appear to bo protected against freezing' . , ...

e Does the hand hose on the sprinkler system appea, to be sat,s!actory' - iiiiii CONTROL VALVES (See 11em 14)

a. Are all sprinkler system con!l'ol valve, and all other valves ,n the appropr;a1e open or closed pos,1,on?

ml ••

b. Are all control valves in me open pos,tion and locked . sealed or equ,pped w,th a tamper sw,tcn?

ii:: WATER SUPPLIES (See Item 15) .. :· a.. Was a water !low test ol main dra,n made al the spr,,,kle, riser' ::: .: .. TANKS. PUMPS, FIRE DEPARTMENT CONNECTIONS { a Are f,re pumps. gravity tanks. reservo1rs and pressure tanks ,n good cond,t,on and oroperly ma,nla,ne,cP

b. Are f,re department connect ions ,n sahslacto,y cond1t1on. coupl,ngs lree . caps 1n place. and check valves t,ghl1

I Are they accessible arid v,s,ble?

WET SYSTEMS (See Item 13) I ill!!! a Are cold weather valves (0 S &Y) ,n the appropria1e open or closed pos,\ion' b Have antifreeze sys1em solutions been 1esled?

C Were the antifreeze 1est results satisfactory'>

6 DRY SYSTEMS (See Items 10 to 14) a Is the dry val..-e in service?

b Are the a,r preHure and pr1m1ng wlter level ,n accordance with !he ml nulacturer"s ,nstruct,ons?

C Has the operation o! tho 111r or nitrogen supply been tested? ts ,1 .,, serv,ce?

d Were low points dra,ned during th is 1nspec1,on"">

& Did quick-opening dev,ces operate satisfactorily? J

'· D•d the dry val~ tr ip properly dur1ng !he tr,p pressure lest? I

g. Did the heabng equ,oment in !he dry-p,pe valve ,oom operate al me 1,me 01 ,nspec:1,on'

7 SPECIAL SYSTEMS {See Item 16)

11. Did the delug.- or pie-act,on valves operate properly dunng testing?

b. Did the heat-responsive dov,ces operate properly durtng test,ng'

c. D•d tho superv,sory devices operalf! durong testing?

8 ALARMS

a Did •■ter motor and gong test sa1,sfacto,ily?

b. Did electric alarm test salislactorlly?

C Did superv,sory ala rm !lflrv,ce test sat,slactorily'

111111 9 SPRINKLERS

a Are all sprinklers Ire■ lrom corroa,on, loading or obstruction 10 spray discharge' ~ i b Are all sprinklers less than 50 yeara old. including quick response leS6 than 20 years old?

C Is stock ot spare spnnklen; available?

r d Does 1he e•ter,or condition of sorlnkler sys1em appear to be sahslactory' -X X ~y e Temperature. Are spr,nkle~s ot p,opet temperature ratings lo, the,r locations?

"Explain '"No- Answers on Page 2 tNo1 ,ppl,c:,ble

11115 'O' Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

REPORT TO ----,,1----=--------'-'----"'--'-------------DATE _'f/ .......... ·3 .... • .... Z........,.tJ.=------------C1Jmm1,1nlfr1 C4,,,tt,,fi'On4 I c:-.~h,,,f'

Wet Systems No. ' Make and Model·

Dry Systems No I Make and Model

Special Systems No: Type

Condition? Make and Model

10 Date dry pipe valve trip tested (control valve partially open) 11 Date dry pipe valve trip tested (control valve fully open) 12 Dale quick opening device tested 13 Dale deluge or preaction valve tested

N' rl-"Dt

Control Valve Maintenance Table

Control Valves Number Type Open_,. Secure_sl. Closed Signs

City Connection Control Valve IA.IP

Tank Control Valves

Pump Control Valves -Secti011al Control Valves z.. 11.t/1~11

System Control Valves 2. Al!' I .,,..,.,...

Other Conlrol Valves

15 WATER FLOW TEST

See Trip Test Report See Tnp Test Report See Trip Test Report See Trip Test Report

Explam Abnormal Condition

Water Pressure? (aO City PSI Tank PSI Fire Pump ___ _ Jockey Pump __ _

Water Flow Tes_t?_•r-10,..S __________ (II none macle Why?)

PSl

Tes! Pipe Test Pipe PreSlluro Flow Pressure Tes1 Pipe Tesl Pipe Prussure Flow Prussure

,~B-...c.LJ ___ j-=----; ~::, ______ ~...--elor_e--:_l ~'f_e$$U~re~, -f~A1te----1r--ir~--Loca=1ed====s-1_ze ==Belor-e~-"Pre=ssure==Afte=r

16. 5 Year IPI. Gauges, FDC Check Valve, Com me ts

a. When was the system insta!led._---'"--'--'-"" ..... QuJ.._t]'-'------------------------------------

b. When was the Last 5 year done.--""'-'=-------------------------------------c Whon is lh6 Next 5 yeur due. __ __..-_...., ___________________________________ _

d. Comments _______________________________________________ _

Auxiliary Equipment No.? ____ Type ________ Location _____ Test Result? __________ _

17. Explain any "No• answers and comments:

18a. Is the fire sprinkler system monitored by 24 HA monitoring? IZl Yes D No

18b. This fire sprinkler system is required to ha.,,e 24 HR monitoring. Failure to monitor the fire sprinkler system can ultimately !ead to substantial loss.

Initial he<e to acknowledge: --------- 19 Although these comments are no! the result of an en91neering review. the following desirable improvements are recommended:

MAHONEYt~ Fire Sprinkler, Inc. (

11115 'O' Street • Omaha, NE 68137

(402) 553--1221 • (402) 553-4545 FAX

DRY PIPE VALVE TRIP TEST REPORT

REPORT TO ~M-.......... rh u,r-l'u.,h'\'.:>t"'4r uui.¾tt INSPECTION NO. ________ _

STREET :21'2.0 \J. '16" ~ tt CITY L, ....... i..ol... STATE ~-lJE ____ CONTRACT NO

DATE OF TRIP TEST Cj. 3 ·-z..lL. TECHNICIAN _ __.:B-=--c-~=-¥~1-:=--------------------- NOTE: BEFORE ANY ORY PIPE VALVE IS TRIP TESTED, THE WATER SUPPLY LINE TO IT SHOULD BE THOROUGHLY FLUSHED THE TWO INCH

DRAJN BELOW THE VALVE SHOULD BE OPENED WIDE. AND WATER AT FULL PRESSURE SHOULD BE DISCHARGED LONG ENOUGH TO CLEAR THE PIPE OF ANY ACCUMULATION OF SCALE OR FOREIGN MATERIAL. IF THERE IS A HYDRANT ON THE SUPPLY LINE, THIS HYDRANT SHOULD BE FLUSHED BEFORE THE TWO INCH DRAIN IS OPENED THE DRIP VALVE ON THE ORY PIPE VALVE SHOULD BE CHECKED BEFORE TRIPPING THE DRY PIPE VALVE, TO SEE THAT IT IS 1N OPERATING CONDITION.

ORV PIPE VALVES SYSTEM NO. ( / ) SYSTEM NO. ( I SYSTEM NO. ( ) SYSTEM NO. (

VALVE SERIAL NUMBER W{)Q39)4:,1f MANUFACTURER(NAME) ,/, · v Jn ..

VALVE MODEL r ... - 11ooo VALVE SIZE If• INCH INCH INCH

CONTROLLING (LOCATION) ,A,l-,1n-_ l

INCH

SPRINKLERS (NUMBER) <><'>D (APPROX_) {APPROX) (APPROX.) (APPROX)

DATE LAST TRIP TESTED? ?-•-~

DATE LAST OPERATED? ;,.:,'2- 'a, PRESSURE AIR 3D LBS LBS LBS LBS

BEFORE TEST WATER eoo LBS LBS LBS LBS

SIZE ANO LOCATION OF TEST VALVE ½ __ e..-u.f

WAS GATE VALVE BELOW ORV VALVE OPEN

3, WIDE AT TEST? IIF NOT HOW MANY TURNS?)

AIR PRESSURE JO LBS. LBS. LBS LBS

WATER TRIPPED AT WATER PRESSURE c.o LBS LBS LBS LBS

TIME MIN:z._i,I.. SEC MIN SEC MIN SEC MIN SEC

IF SYSTEM FLOODED, LIST TIME WATER

REACHED TEST OPENING MIN SEC MIN SEC MIN SEC MIN SEC

PERFORMANCE 'QI,,,

INTERIOR OF BODY

MOVING PARTS

VALVE CONDITION RUBBER FACING

SEATS

RESET? ~, .. <'.

DID ALARMS OPERATE AT TRIP TEST?

I

ALL LOW POINT DRAINS BLOWN OUT? (?)

WATER CONTROL VALVE LEFT

OPEN ANO SEAlEO?

ALAFU.O CONTROL VALVE LEFT

OPEN

QUICK OPENING DEVICES S'l'STEM NO. ( ) S'l'STEM NO. ( J SYSTEM NO. ( ) S'l'STEMNO.( )

DEVICE SERIAL NUMBER

MANUFACTURER (NAME) I

TYPE ANO MODEL \. I

AIR PRESSURE IN UPPER CHAMBER V LBS LBS LBS LBS

QUICI( OPENINO DEVICE TRIPPEO AT JIEO.. LBS SEC LBS SEC LBS SEC LBS

PERFORMANCE

QUICK OPENING DEVICE LEFT IN SERVICE

ANO CONTROL OPEN

111:MARKS _________________________________________________ _

CO!tl'IAREOWITH: ----------------------------

DATI _______________ _

Backflow Preventer Test Form

402.441.5912 • e-mail: Backflow@lincoln.ne.gov • FAX: 402.441.8003

Return to: Lincoln Water System Backflow 2021 North 27th Street, Lincoln, NE 68503

Business/Building Ct2mmu nt '6.J c,~n ~ h 'evi.4/ U,. fe,,,- Contact Person _____________ _

Service Address 2 ·n .. o vJ . .Ja ... pg.-,, ~r L,.,,u,/n, NE. Ca85Z..Z. Suite# ___________ _

Phone# e-mail: --------------- ----------------------- Device Location+fYk.......,c~-h~'.t~t1'~-------------------------------ltlAnnualTest □ Repair □ Newlnstallation

J!J DC O RPP Serial #: ::JE-Oqdi Size: 4-" Manufacturer: Wa. f-:ts Model#: ______ 75=--....7 __

0 Replacement

0 DC O RPP Serial #: Size: Manufacturer: Model#: ------- ------ ---- -----

0 Domestic Containment □ irrigation 0 Fire Service □ Boiler 0 Carbonator

□ swimming Pool □ cooling Tower □ water Cooled Ice Maker 0 Other (Desc): _____ _

Shut off #2

Check Valve #1

Check Valve #2

Reduced Pressure-Double Check Valve

Held~Yes ONo

3. PSID Held ¢ves □ No ---

4-. __ l _____ PSID Heldj4Yes □ No

Relief Valve (RP only) Opened at --- PSID ---

Pressure Vacuum Breaker

Shut off #1 Held Dves O No

Shut off #2 Held O Yes O No

Check Valve Held at --- ___ PSID

Air vent opened at __ _ PSID ---

Final Test: Check Valve #l'. Check Valve #2 Pressure Relief PVB/SVB

Closed Tight Oves □ No Check Valve PSID

PSID PSID Replaced PSID Air Inlet PSID

I hereby certify the above backflow preventer has been tested in accordance with all rules and regulations of the State of Nebraska Health and Human Services, Department of Regulation and Licensure, Title 179, and the Lincoln Water System Title 17, and that all readings are true and accurate to the best of my ability. Must be returned to LWS within 30 days of performing test.

State Certified Technician (Please Print) Grade 6 Certificate# Cell/Phone#

:B c--::x"::::

State Certified Technician (Signature) Customer {Signature) Date of Test

02.of'v39J4 Test Gauge Manufacturer Test Gauge Serial # Date of Calibration

Comments: _______________________________________ _

PLEASE TYPE OR PRINT LEGIBLY

Whije Copy· LWS Yellow Copy· Contractor Pink Copy • Business

LOCATION OF SYSTEM:

INSPECTION DA TE

UNDERGROUND TEST CERTIFICATION (FORM 85-AB) INITIAL ACCEPTANCE OF SYSTEM

ABOVEGROUND TEST CERTIFICATION (FORM 85-AC) REINSPECTION DUE TO REMODEL, REPAIR, ETC

REPORT OF INSPECTION / PERIODIC ANNUAL INSPECTION

ORY PIPE VALVE TEST / BACKFLOW PREVENTER TEST

ITEM# DIRECTORY DEFICIENCIES

1 -WET RISER

2- DRY RISER

5 - BACKFLOW PREVENTER ITEMIZE DEFICIENCIES NOTED ON INSPECTION AND

6 - STANDPIPE ANY OTHER PERTINENT COMMENTS ON SYSTEM 3 - PREACTION RISER

4- ARE PUMP

TAG#

t.1,.71d'h7

J/.9/lJd

1JIID1S'

[◄ IN COMPLIANCE

7-0THER

ITEM#

I

I

11115 'O' Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

MAJOR DEFICIENCIES: COMMENTS

STATUS OF SYSTEM - CHECK ONE

■ MINOR DEFICIENCIES ■ MAJOR DEFICIENCIES

NE LICENSE#: 18021

TESTER BFP LICENSE#::

OWNER REPRESENTATIVE SIGNATURE

SEND TO: NEBRASKA STATE FIRE MARSHAL- 248 SOUTH 14TH ST - LINCOLN, NE 68608-1804

M.AHONEY

11115 'O'Street • Omaha, NE 68137

(402) 553-122_1 • (402) 553-4545 FAX

REPORT OF INSPECTION

REPORT To Co,,,rnr,c niry VJrftMlan,I Caohr WHJA

ADDRESS _________________ _

OATE_4....__·3=---·~-=--~------

_______ TECHNIClAN ~8-•_ltH."-1-~~------

Owners Seclion (To be answered by owner or occupant) A- Describe any lire proteclion modifications or occupancy hazard changes since previous inspection. __________________________ _

8. When was 1he last 5 yeardQn,e?----=2=01.0=-==---------------------------------------------ln9P9(:lor'I S.ctlon (All responses reference curren1 inspect,on)

GENERAL Yes NAt No"

---·--·--·--------·-l----l--+!!~~:.11~·:=+----a Is the building occupied' -b Are an systems in service? . ______ -------------------+---+----t c Is there a minimum ol 18 in (457mm) clearance be1ween the top of the storage and the spm,lcler deflector? ,::: .. •w-----d In areas protected by wet system. does the buildmg appear to be properly heated in all areas. includmg blind attics ::::::

and perimeter areas, where accessible? Do all exterior openings appear to be protected against freezing' ••••••1-----e Does the hand hose on the sprinlcle, system appear to be sat1sfaclory? ~--

2 CONTROL VALVES (See Item 14) I ::::.i a Are all sprinkler system control valves and all other va!ves 1n 1he appropriate open or closed p0s1tion? :n:::::-

b. Are all control valves ,n the open position and locked. sealed or equipped with a tamper switch' m· 1----- 3 WATER SUPPLIES (See Item 15) •:•

a. Was a water tlow test ot main drain made a, the sp11nkler riser? . lel ,._ __ _

4 TANKS, PUMPS, FIRE DEPARTMENT CONNECTIONS -J

a. Are fire pumps. gravity tanlcs. reservo1rs and pres.sure tanks 1n good cond,11on and properly mamta,ned' b Are lire depa<tment connechons 1n saustaclory condil1on. couplings tree. caps 1n place. and check valves tighP

An, they ac,ce5sible and vi:sible? -~ - -------------- 5 WET SYSTEMS (See llem 13)

a. Are cold weather valves (0 s &Y l 1n lhe appropr,ate open or closed position~

b. Have antifreeze system solutions been tested?

c Were the antifreeze test rnulls ~tislactory?

6 DAY SYSTEMS (See Items 10 to 14)

a. Is the dry valve 1n service?

b Are the air pressure and priming water level 1n accordance with 1he manutacturer"s ins1ructions?

c. Has !he operation o! the air or nitrogen supply been tested' Is 11 1n service'

d. Were low poin!s drained e1ur1ng this inspection?

e Did quick-opening devices operate satistactor,ly?

f_ Did lhe dry val,oe trip properly during the tr1p pressure test?

g. Did the healing equipment in the dry-pipe valve room operate al the time ot 1nspect1on?

7 SPECIAL SYSTEMS (See Item 16)

----- --r-,-t..-.....-::a.:a11.t----l ::~ .. . .. : .. .

a Did the delugeo or pre-action valves operate properly dur1ng 1eshng? ··----------------------+-----+--+---+-----

b. Did the heat-responsive dev,ces operate properly during testing?

c. Did !he supervisory devices operate during testing?

8 ALARMS

a. Did water motor and gong tes! satisfactorily?

b Did electric alarm test salisfactorily?

c Did supervisory alarm service test satislactoriiy?

9 SPRINKLERS

a Are all sprinklers tree lrom corros;on. loading or obstruchon lo spray discharge' b Are all sprinklers less tt\an 50 years old, including quick resp:mse less than 20 years old?

c Is stoclc of spare sprinkle~ available?

d Does the e~te11or cone11t,on of sprinkler system appear 10 be satisfactory? -------------------·- - - ........ 1 .,....,...,.,.1- ___ ,_

e. Temperature. Are sprinklers ol proper temperature ratings for their locat1ons? --••

·E~pla1n ··No" Answers on Page 2 tNot a1>phc1ble

11115 'O' Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

REPORT TO ........ c,<,;;,c..:.,,,_,,,:,_· --="'-'ri'-1-''ry..:+--'C.......,a,t..:f'...::t""t_;._l-,....,iqc..c,,_.,"-"-'---"''""'--"'nh'--_r---'-vl_ll_it ________ DATE __ q_._3_·_Z4 _________ _

Wet Systems No: 2. Make and Model· 2.J 4-" \.J 1=S

Ory Systems Make and Model:

Special Sys1ems No: Type:

Condition? Make and Model: t..j• De.

10 Date dry pipe valve trip tested (control valve partially open)

11. Oate dry pipe valve trip tested ( control valve fully open)

12. Oate quick opening device tested

13. Date deluge or pre action valve tested

I J

14 Control Valve Maintenance Table

See Trip Test Report Sae Tnp Test Repor1 See Trip Test Report See Trip Test Report

Control Valves Number Type Open Secured Closed Signs Explain Abnormal Condition

City Connection Control Valve PAI ✓ ✓ Tank Control Valves Pump Control Valves Sectional Control Valves ~ ?J=' .,,-- System Control Valves ~ pjS:' .........-- .....- Other Control Valves

15. WATER FLOW TEST

Waler Pressure? 70 City ___ _ PSI Tank. ____ PSI Fire Pump ___ _ Jockey Pump ___ PSI

Water Flow Tes_t?_ . ...,\o.a,t5=..---------- (1f none made. Why'}

Test Pipe Located

Test Pipe Pressure Before

16. 5 Year I Pl, Gauges, FOG Check Valve, Comments

Flow

Pressure Pressure

After Test Pipe Located

Test Pipe Size

Pressure Before

Flow Pressure

Pressure After

a. When was the system insta!led._~0~1.0~-------------------------------------

b. When was the Last 5 year done. --=L~0:;;..2==D:,__ ___________________________________ _

c. Wilen is tile Next 5 year due. _ ___,Z.,_D=..-. ____________________________________ _

d. Comments _______________________________________________ _

Auxiliary Equipment No.? ____ Type ________ Location ______ _ Test Result? __________ _

17 _ Explain any "No" answers and comments:

1 Ba. Is the fire sprinkler system monitored by 24 HR monitoring? ~es D No

18b. This fire sprinkler system is required to have 24 HR monitoring. Failure to monitor the fire sprinkler system can ultimately lead to substantial loss.

Initial here to acknowledge: ---------

19. Although these comments are not tile result of an engineering review. the following desirable improvements are recommended:

Return tQ: Lincoln Water System Backflow 2021. North 27th Street, Lincoln, NE 68503

Business/Building(An,rnuoify Corrultru•oi Cu,h;- WHtA Contact Person ____________ _

Service Address 2, "1..0 W • Vll.o Doc"' Sf G'nuin, /JE lo2:lS'22 Suite# __________ _

Phone# ______________ e-mail: ____________________ _

Device Location /Y}eth /z. M

IZi Annual Test O Repair 0 New Installation

.la DC O RPP Serial#: 5~ ~l.'Z.. 7 "-

0 Replacement

Size: ti-•

0 DC O RPP Serial#: Size: ------ ·-----

0 Domestic Containment O Irrigation ~ Fire Service

Manufacturer: wafh Model#: ...,.7-=!:'-'7._ __

Manufacturer: ____ Model#: ____ _

0 Boiler 0 Carbonator

□swimming Pool □ cooling Tower □ water Cooled Ice Maker 0 Other (Desc): _____ _

Reduced Pressure-Double Check Valve Pressure Vacuum Breaker

Shut off #2 Held ~ Yes □ No Shut off #1 Held O Yes O No

Check Valve #1 2.... PSID Held c;J'""Yes O No Shut off #2 Held Oves O No ------

Check Valve #2 '3 • B PSID Held ~Yes O No ------ Check Valve Held at __ _ ___ PSlD

Relief Valve {RP only) Opened at __ _ ___ PSID Air vent opened at __ _ _ __ PSID

Final Test: Check Valve #1 Check Valve #2 Pressure Relief PVB/SVB

Closed Tight Oves □ No Check Valve PSID

PSID PSID Replaced PSID Air Inlet PSID

I hereby certify the above backflow preventer has been tested in accordance with all rules and regulations of the State of Nebraska Health and Human Services, Department of Regulation and Licensure, Title 179, and the Lincoln Water System Title 17, and that all readings are true and accurate to the best of my abillty. Must be returned to LWS within 30 days of performing test.

®l.- 5 53 - rz.:t. I State Certified Technician (Please Print) Grade 6 Certificate#- Cell/Phone# llt>v'.:\f\ .

State Certified Technician (Signature) Customer (Signature) Date of Test tn id:vJP:H: • Test Gauge Manufacturer Ol.06J3S 'I

Test Gauge Serial# Date of Calibration

Comments: _____________________________________ _

White Copy• LWS Yellow Copy • Contractor Pink Copy • Business

Return tq: Lincoln Water System Backflow 2021 North 27th Street, Lincoln, NE 68503

Business/Building(,21nmur2c"f!, C!Jotcfr'ornf Cq,,./tr v./Hl.,f Contact Person ____________ _

Service Address 2 720 \,J. v'11,-, C\?,n st- L,Y.c,,0/r, JIJE; '486U Suite# _ __________ _

Phone# ______________ e-mail:. _____________________ _

Device Location...,1;.Mr.:.i.i.c.ibJ...l!!.E:::...#11~------------------------------

J2l Annual Test O Repair 0 New Installation

Ja'oc WRPP Serial#: SA ·05!t((, Size: 3" Manufacturer: vvaf/$ Model#:757

0 Replacement

Ooc □ RPP Serial#: Size: Manufacturer: Model#:

JZf Domestic Containment 0 Irrigation 0 Fire Service □ Boiler 0 Carbonator

□ swimming Pool □cooling Tower □ water Cooled Ice Maker 0 Other (Desc): _____ _

Reduced Pressure-Double Check Valve Pressure Vacuum Breaker

Shut off #2 Held)21'Yes □ No Shut off #1 Held □ Yes □ No

Check Valve #1 I ~ VJ PSID Held,,ef'Yes O No Shut off #2 Held O Yes O No

Check Valve #2 I. e PSID HeldJ:1" Yes O No Check Valve Held at___ _ __ PSID

Relief Valve (RP only) Opened at __ _ PSID --- Air vent opened at __ _ ___ PSID

Final Test: Check Valve 111 Check Valve #2 Pressur:e Relief PVB/SVB

Closed Tight Oves □ No Check Valve PSID

PSID PSID Replaced PSID Air Inlet PSID

I hereby certify the above backflow preventer has been tested in accordance with all rules and regulations of the State of Nebraska Health and Human Services, Department of Regulation and Licensure, Title 179, and the Lincoln Water System Title 17, and that all readings are true and accurate to the best of my ability. Must be returned to LWS within 30 days of performing test.

Bao,-, lo.ts State Certlfied Technician (Please Print) Company Grade 6 Certlficate# Cell/Phone#

3&4,M:

State Certified Technician (Signature) Customer {Signature) Date of Test

02.f13!3'8 1/.

Test Gauge Manufacturer Test Gauge Serial# Date of Calibration

Comments: _____________________________________ _

White Copy· LWS Yellow Copy- Contr~ctor Pink Copy· Business

Return tQ: Lincoln Water System Backflow 2021 North 27th Street, Lincoln, NE 68503

Business/BuildinF:t'.:m:rec-fr'orn/ Cvn,,,,v,.,-~ ~ wtffA Contact Person ____________ _

Service Address Z 7-JC vJ. "4,,Dt,r., sf Li'nco/n,f.JE., "962-z.. Suite# ------------ Phone# ______________ e-mail: ____________________ _

Device Location,..J/YJ=t""-,::.1'1c......,::e~IM:..:.._ _____________________________ _

IA Annual Test O Repair O New Installation

Ooc ll(RPP Serial#: (p7o54 Size: ___ /'_' __ _ Manufacturer: 1,,./affs Model#: LFt;1qQT

0 Replacement

0 DC O RPP Serial #: Size: ------ ----- Manufacturer: Model#: ---- -----ef Domestic Containment O Irrigation 0 Fire Service □ Boiler 0 Carbonator

□ swimming Pool □ cooling Tower □ water Cooled Ice Maker Oother (Desc): _____ _

Shut off #2

Reduced Pressure-Double Check Valve

Held~Yes □ No

Check Valve #1 _7_. ___ '+ __ PSID Held ~Yes O No

Check Valve #2 __ 1_-___ C..0 __ PSID Held~Yes □ No

Relief Valve (RP only) Opened at 2... • _8"""-_PSIO

Pressure Vacuum Breaker

Shut off #1 Held Dves O No

Shut off #2 Held Dves □ No

Check Valve Held at PSIO --- ---

Air vent opened at __ _ __ PSID

Final Test: Check Valve #1 Check Valve #2 Pressure Relief PVB/SVB

Closed Tight Dves □ No Check Valve PSID

PSID PSID Replaced PSID Air Inlet PSID

I hereby certify the above backflow preventer has been tested in accordance with all rules and regulations of the State of Nebraska Health and Human Services, Department of Regulation and Licensure, Title 179, and the Lincoln Water System Title 17, and that all readings are true and accurate to t he best of my ability. Must be returned to LWS within 30 days of performing test.

State Certified Technician (Please Print)

1t.i6 /\-< State Certified Technician (Signature) raray11sf Test Gauge Manufacturer

Company

Customer (Signature)

Test Gauge Serial #

Grade 6 Certificate# Cell/Phone#

Date ofTest

Date ~:bration

Comments: _____________________________________ _

White Copy• LWS Yellow Copy• Contractor Pink Co~• Business

Return to: Lincoln Water System Backflow 2021 North 27th Street, Lincoln, NE 68503

Business/Buildi~fl.t'«:r◄eh'Pt!a/ c;,,,,,,,mif1 ltttle( \I,/ fl U Contact Person. ____________ _

Service Address272D w. Var,Dorn ~f ll'),,,;fn ,lie, (afSZZ.. Suite# __________ _

Phone# ______________ e-mail: _____________________ _

Device Location Meth lJtt -,,,..........,_.:........,;'-'--''---------------------------------

El Annual Test O Repair 0 New Installation

Ooc lZJ RPP Serial#: 32235 Size: 2-" Manufacturer: waffi Model#: q,qG.T

0 Replacement

Ooc □ RPP Serial It: Size: Manufacturer: Model#:

0 Domestic Containment ,91 Irrigation D Fire Service 0 Boiler 0 Carbonator

□ swimming Pool □ cooling Tower □ water Cooled Ice Maker Oother (Desc): _____ _

Reduced Pressure-Double Check Valve Pressure Vacuum Breaker

Shut off #2 Held )ZJYes □ No Shut off #1 Held O Yes O No

Check Valve #1 9. (L) PSID Held !2lYes □ No Shut off #2 Held O Yes O No

Check Valve 112 I . 2., PSID Heldt' Yes O No Check Valve Held at ______ PSID

Relief Valve (RP only) Opened at 3. 4- PSID Air vent opened at___ _ __ PSID

Final Test: Check Valve #1 Check Valve #2 Pressure Relief PVB/SVB

Closed Tight Dves □ No Check Valve PSID

PSID PSJD Replaced PSID Air Inlet PSID

I hereby certify the above backflow preventer has been tested in accordance with all rules and regulations of the State of Nebraska Health and Human Services, Department of Regulation and Licensure, Title 179, and the Lincoln Water System Title 17, and that all readings are true and accurate to the best of my ability. Must be returned to LWS within 30 days of performing test.

State Certified Technician (Please Print)

13.◊ 6 ,< State Certified Technician (Signature)

IY/Jdwest Test Gauge Manufacturer

Customer (Signature)

QUJ9di0'f Test Gauge Serial#

Grade 6 Certificate# Cel!/Phonetl

Date of Test

4h4 Date dt Calibration

Comments: _______________________________________ _

White Copy - lWS Yellow Copy• Contractor Pink Copy• Business

LOCATION OF SYSTEM:

ABOVEGROUND TEST CERTIFICATION (FORM BS-AC)

/ REPORT OF INSPECTION

DRY PIPE VALVE TEST

ITEM # DIRECTORY

1 -WET RISER

2- DRY RISER

3 - PREACTION RISER

4- FIRE PUMP

5 - BACKFLOW PREVENTER

6 - STANDPIPE

7-0THER

INSPECTION DA TE

I

INITIAL ACCEPTANCE OF SYSTEM

REINSPECTION CUE TO REMODEL, REPAIR, ETC

/ PERIODIC ANNUAL INSPECTION

,, BACKFLOW PREVENTER TEST

DEFICIENCIES

ITEMIZE DEFICIENCIES NOTED ON INSPECTION AND

ANY OTI-iER PERTINENT COMMENTS ON SYSTEM

TAG# ITEM# MAJOR DEFICIENCIES,' COMMENTS

I s

MAHONEY l,~ Fire Sprinkler, Inc.~

11115 '0' Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

SPECTOR SIGMA TURE

NE LICENSE#: 18021

TESTER BFP LICENSE #: "1~3

OWNER REPRESENTATIVE SIGNATURE

SEND TO: NEBRASKA STATE FIRE MARSHAL- 246 SOUTH 14TH ST - LINCOLN, NE 68508-1804

11115 'O'Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

REPOHT OF INSPECTION

REPORTTO [ ornmu,·11 c(),,-~cl,~P'lt',.I C,t'l,-fu Tflf.,,( DATE 9· 3 • LI./.

ADDRESS 2, z..o w. ,h.., :Do..-n S -t- L ,' n1..o/ n, t,.l'E:., C..:, 9~ z...z. TECHNICIAN 13,loya.

Owners Section {To be answered by ownar or occupant) A. Describe any !ire protection modifications or occupancy hazard changes since previous Inspection. _________________________ _

B. When was the last 5yeardone?__,2.-..a'0"-"'2.-=--""2..=--------------------------------------

1n1pactor·1 S1tellon (All responses reference current ,nspection)

GENERAL Yes N.A.t No• a, Is the building occup,ed? •:•••:~ •••• b Are all systems 1n service? :·•·:• c. Is there a minimum of 18 in (457mm) clearance between tne top 01 Ine storage and the spnnkler deflector? •••• =••••= d In areas protected by wet system. does the building appear lo be properly heated In all areas. including blind attics •••••• •••••• and perimeter areas. where accessible? Do all exterior open,ngs appear lo be protected against freezing? •••••• e Does the hand hose on the spr1nkler system appear to be satisfactory? _ _../.,._ 2 CONTROL VALVES ISee Item 14) •••••• •••••• a Are all sprinkler system control valves and all othe1 valves ,n the appropr,ate open or closed position? •::·•· b. Are all control valves In the open position and locked. sealed or equipped with a tamper switch? ••••• •••••• 3 WATER SUPPLIES (See Item 15) !I •••• ·:•• a Was a water flow test of main drain made at the spronkler riser? •••

4, TANKS, PUMPS, FIRE DEPARTMENT CONNECTIONS

'>( a, Are fire pumps. gravity tanks. reservoirs and pressure tanks ,n good cond it,on and properly maintained?

b Are fire department connections in satisfactory cond,t,on. couphngs tree caps ,n place. and check valves toght?

Are they accessible and visible? I

5. WET SYSTEMS I See Item 13) I ·••:;:; •••• a. Are cold weather valves (0 S &Y ,) in the appropnate open or closed posit,on' •••••• b Have antifreeze system solutions been tested?

C Were the antifreeze test results satisfactory?

6 DAY SYSTEMS (See Items 10 to 14)

a. Is the dry valve In service1 b Are the air pressure and priming water level ,n accordance with the manufac.turer's iMtructions?

c. Has the operation of the a1r or nitrogen supply been tested? Is 11 in service?

d . Were low pmnts drained during this inspect ion?

e Did quick-opening devices operate satisfac1only?

I Old 1he dry valve trip properly during lhe tnp pressure test?

g. Did the heating equipmenl in the dry-pipe valve room operate at the time 01 ,nspechon?

7. SPECIAL SYSTEMS (See Item 16) a Did the delugP or pre-action valves operate properly durong testing?

b Did the heat•respons,ve devices operate properly dunng tes1 ing?

C Old the supervisory dev,ces operate during testmg?

8 ALARMS

a Did water motor and gong test satisfactorily?

b Did electric alarm test satisfactorily?

C Did supervlso1y alarm service test sat isfactorily?

111111 9 SPRINKLERS

111 Art1 all sprinklers fret1 from corrosion. loading 01 obstruction to spray discharge? r.:!1; b. Are all sprinklers less than 50 years old. including quick response less than 20 years old?

C Is stock of spare sprinklers available?

d Does the extenor condition ot sprinkler system appear to be satisfactory?

Temperature. Are sprinklers of proper temperature 1atl rigs for their locations?

~~~ £ ~.:z:

e

"Explain '"No" Answers on Page 2 fNot apphcable llll5 'O'Street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

AEPORTTO Co,,.,,rnu11•·+~ Cocfee,;,!iona.l l.<n-fc., Wet Systems No: I Make and Model:

Dry Systems No: Make and Model:

Special Systems No: Type:

Condition? Make and Model:

10. Date dry pipe valve trip tested (control valve partially open) 11 Date dry pipe valve trip tested (control valve fully open)

12. Date quick opening device tested

13. Dale deluge or pre action valve tested

14, '+" W'F-S.

cl-" Dt

I

I

Control Valve Maintenance Table

DATE l:1·3•2.'4

See Trip Test Report See Trip Test Report See Trip Test Report See Trip Test Report

Control Valves Number Type Open Secured Closed Signs Explain Abnormal Condition City Connection Control Valve -Pr-J v ~

Tank Control Valves

Pump Control Valves Sectional Control Valves --System Control Valves 2. 'R\:= V V

Other Control Valves

15. WATER FLOW TEST

Water Pressure_? _{p_'D __ City ____ PS\ Tank PSI ---- Fire Pump ___ _ Jockey Pump ___ PSI

Water Flow Tes_t? _ _,y_.,4.,.s, __________ (If none made. Why?)

Test Pipe Located

Q.1

Test Pipe Size

2"

Pressure Elefore

<PO

16. 5 Year IPI, Gauges, FDC Check Valve, Comments

Flow Pressure

.;"o

Pressure After

(i'ID

Test Pipe Located

Test Pipe Size

Pressure Before

Flow Pressure

Pressure After

a. When was the system insta!led._-='-0_1_7""--------------------------------------

b. When was the Last 5 year done. ----..-."2.;::... __________________________________ _

c. When Is the Next 5 year due. ___ ..._ ______________________________________ _

d. Comments _______________________________________________ _

Auxiliary Equipment No.? ____ Type ________ Location _______ Test Result? __________ _

17. Explain any "No" answers and comments:

18a. Is the fire sprinkler system monitored by 24 HR monitoring? ~ Yes D No

18b. This fire sprinkler system ls required to have 24 HR monitoring. Failure to monitor the fire sprinkler system can ultimately lead to substantial loss.

Initial here to acknowledge: ---------

19. Although these comments are not the result of an engmeering review. the following desirable improvements are recommended:

402.441.5912 • e-mail: Backf1ow@lincoln.ne.gov • FAX: 402.441.8003

Return to: Lincoln Water System Backflow 2021 North 27th Street, Lincoln, NE 68503

-rHu Business/Building Corrim1,11n t""j (4rl"ceft,mal C,a-le,: Contact Person _____________ _

Service Address 2 ,'l..0 I)/. ':P,~ l-brn st L,'y,.c.,o/n. IJE, G;:.9 !:°2...'Z ... Suite# ___________ _

Phone# ______________ e-mail: ____________________ _

Device Location ty'}e_t..J,,, /!...M

~Annual Test □ Repair 0 New Installation

!A'oc O RPP Serial#: cOO~'l...2...

0 Replacement

Size: '-+ • ¥'Flo.J Manufacturer: ,v-e.t.+ Model#: 1?,e..-~u U>

0 DC O RPP Serial #: Size: Manufacturer: Model#: ------- ------ ---- -----

0 Domestic Containment O Irrigation 121' Fire Service □ Boiler 0 Carbonator

□ swimming Pool □ cooling Tower □ water Cooled Ice Maker 0 Other {Desc): -------

Shut off #2

Reduced Pressure-Double Check Valve

Heldflves □ No

Check Valve #1 2 • q PSID Held.laves □No ---

Check Valve #2 o • 0 PSID Held □Yes ~No ------

Relief Valve (RP only) Opened at __ _ ___ PSID

Pressure Vacuum Breaker

Shut off #1 Held O Yes O No

Shut off #2 Held O Yes O No

Check Valve Held at PSID --- ---

Air vent opened at __ _ ___ PSID

Anal Test: Check Valve #1 Check Valve #2 Pressure Relief PVB/SVB

Closed Tight Oves □ No Check Valve PSlD

PSID PS!D Replaced PSID Air Inlet PSID

I hereby certify the abo\/'e backflow pre\/'enter has been tested in accordance with all rules and regulations of the State of Nebraska Health and Human Services, Department of Regulation and Licensure, Title 179, and the Lincoln Water System Title 17, and that all readings are true and accurate to the best of my ability. Must be returned to LWS within 30 days of performing test.

State Certified Technidan {Please Print) fYWzartlJj f:tYe Compan

&vk::» State Certified Technician (Signature) Customer (Signature) f}1 ,e:!J£> /: OLD6t3'8 If.

Test Gauge Manufacturer Test Gauge Serial#

Comments: ~~d +¼ 2. ~.ebu.~\d k..t +

PLEASE TYPE OR PRINT LEGIBLY

White Copy • LWS Yellow Copy• Contractor Pink Copy• Business

Grade 6 Certificate#

</,Oz...- 5153-/1.'LJ Cell/Phone# tJ·$·Z.'I, Date ofTest

Date of Calibration

Return to: Lincoln Water System Backflow 2021 North 27th Street, Lincoln, NE 68.503

Business/Buildingc,....,...,,.#'T, "J urrulr,,,11I (en{u: Ttlu Contact Person _____________ _

Service Address 2. -n .. o r,,J. Ve,;, [)on, ,+ l,t,t tolr1, 1,1/E., '1,ISU Suite# ------------ Phone# _______________ e-ma i 1: _____________________ _

Device Location~~~e .. e, __ l__._P,,, _______________________________ _ r;i/ Annual Test O Repair □ New Installation

~ DC O RPP Serial #: t:Jl,.-0411'8

0 Replacement

Size: 3" -----

0 DC O RPP Serial #: Size: ------- ------

0' Domestic Containment O Irrigation 0 Fire Service

Manufacturer: N:>1" Model#: 757 ----"-;:;......;;. __ _

Manufacturer: Model#: ---- -----

□ Boiler □ Carbonator

□swimming Pool □cooling Tower □water Cooled Ice Maker Dother (Desc): _____ _

Reduced Pressure-Double Check Valve Pressure Vacuum Breaker

Shut off #2 Held 121ves □No Shut off #1 Held Dves O No

Check Valve #1 PSID Held~Yes □ No Shut off #2 Held □ Yes O No ------

Check Valve #2 2. • Z PSID Held IZf ves □ No ------ Check Valve Held at --- ___ PSID

Relief Valve (RP only) Opened at __ _ ___ PSID Air vent opened at __ _ PSID ---

Final Test: Check Valve #1 Check Valve #2 Pressur:e Relief PVB/SVB

Closed Tight Oves DNo Check Valve PSID

PSID PSID Replaced PSID Air Inlet PSID

I hereby certify the above backflow preventer has been tested in accordance with all rules and rel!ulations of the State of Nebraska Health and Human Services, Department of Rel!ulation and Licensure, Title 179, and the Lincoln Water System Title 17, and that all readings are true and accurate to the best of my ability. Must be returned to LWS within 30 days of performinl! test.

State Certified Technician (Please Print) Campa Grade 6 Certificate# Cell/Phone#

~ 'l-:3-z..4 State Certified Technician (Signature) Customer (Signature) Date of Test

/llidr.t1t1 I Test Gauge Manufacturer Test Gauge Serial# Date of calibration

Comments: _______________________________________ _

White Co?Y • LWS Yellow Copy Contractor Pink Copy - Business

LOCATION OF SYSTEM: Nebraska Correctional Center for Women 1107 Rechar e Road York, NE 68467

UNDERGROUND TEST CERTIFICATION (FORM 86-AB) INITIAL ACCEPTANCE OF SYSTEM

ABOVEGROUND TEST CERTIFICATION (FORM 85-AC) REINSPECTION DUE TO REMODEL, REPAIR. ETC

X REPORT OF INSPECTION X PERIODIC ANNUAL INSPECTION

DRY PIPE VALVE. TEST

ITEM # DIRECTORY

1-WET RISER

2-DRY RISER

3 - PREACTION RISER

4-Fire Pum

49012

49013

5 - BA.CKFLOW PREVENTER

6 - STANDPIPE

7-0TI-IER

'NE PUT Ol'T FIRES EVERYWHERE

11115 '0' Street • Omaha, NE 68137

(402) 5.53-1221 • (402) 553-4545 FAX

BACKFLOW PREVENTER TEST

DEFICIENCIES

ITEMIZE DEFICIENCIES NOTED ON INSPECrTON AND AH"'f OTHER PERTINENT COMENTS ON SYSTEM

INSPECTOR SIGNATURE

NE LICENSE#:

OWNER REPRESENT A 11VE SIGNATURE

SEND TO: NEBRASKA STATE FIRE MARSHAL- 2"6 SOUTK 14TH ST- LINCOLN, NE 68508-1804

11115 1 0• street • Omaha, NE 68137

(402) 553-1221 • (402) 553-4545 FAX

REPORT OF INSPECTION

Pump House

REPORTTO Nebraska C_orrectional Center for Women

ADDRESS 1107 Recharge Road, York, NE 68467

DATE 'l-.;J_~---,;;_ .Y TECHNICIANf --V •.a~ \::t /liJ, r

Owners Section {To ba answered by owner or occupanl) A Describe ally !ire prolection modilicalions ot oectlpancy hazard chan9<>s since previous inspeclio11. __________________________ _

B. When was the last5yoor done? _2_0_2_3 _______________________________________ _ lnapedor'1 S.CIIOII (AH responses •elerence current inspection)

1 . O~NlflAL '(es N.A.t No· s a Is the building occup,ed? r-- 11•1:1

b. A1e all sysfe,os ,n &er'vice? ~ .. ::ii C Is thtlre a minimum ol 18 in (457mm) clearance between lhe lop ol the slo,age and the sprinkler delll!clo,., '- •·:: .!

d In areas p<olecled by wet system. does the b1J•ldi11g app-ear to be properly healed ,n all arQas, in,;lud1ng blind a!l~s ?= ·=··1 -and perimeter areas. whare aceess1blo? Do all extetior OJ>"nmgs appear to be protected againsl lrnez1ng?

~ e Does the hand ho,ie on lhe sprink Ie, system appear to be sat1slacto•~"' ..

. CONTROL ¥ALVES (See l1em 1~) ~ •··n Hi • a. Are all sprinkler system control valves and all other •a Ives In the appropr1ale open or closed pos1lion? . :•:-

b. Are al I control valves in lhe open pos;1,on and locked. sealed or equ,ppeo wolh a lamper swi!ch?

t' ..__ .... ::.

. WATER SUPPLIES (See Item 15) y :::·::

a. Wa:s a water flow lest ot main drain made at lhe spr1nk!er riser? - ... : ..

TAMI, PUMPS, FIRE DEPARTMENT CONNECTIONS

I'

~ a. Are fire pumps, gravity tanks. reservoirs and preuure lanks ,n good cond1lion aJ\d properly mainta1neo?

b Are Ii n, departnien I coronechons in .., tis I aclo ry cor,d, hon. c ouDhn gs f r&e. La P" ir, plac8. and che,:k V8hles I 'II hP 11)0

Are they accessible and visible?

WIT SYSTEMS (S9<! llum 13) ~ :s:uz

a. Are cold wealher val_ves (0 S &Y) In the appropriate ooen or closed pos,llon' .,, --···· b. Have an1itr11eze sys1em solutions been tesled'

~ c. Were the an!ilreele lest results sarislectory? --

. DRY SYSTEMS (Sea Items 10 1o 14) - \ a Is the dry 11al•e in ,iervice? - ;

b. Are the air pressure and pr1mI09 water I.,,,eI ,n acc<»dance with lhe marmfac1u,er's 1nstructii:ms• I...

C Has lhe…