Scrubbed USDA FA IT -3.2024 - DeficientFireSystemRepair.pdf

Page: 1 Rev Date: 1/13/2023

FIRE ALARM SYSTEM System Certification Given

CONFIDENCE TEST REPAIRS RED YELLOW WHITE

Frequency Annual: Semi-Annual: Quarterly:

Date of Inspection:

Building Information Building Name: Building Address:

Building Owner: Phone Number: Owner Address:

Description of Property:

Fax:

System & Monitoring Information No

Monitoring Company Address:

Monitoring Company Fax: Monitoring Company E-Mail:

Control Panel Manufacturer: Model Number:

Means of Transmission: Entity which Alarms Are Transmitted:

Location of System:

Onsite location of site-specific software: Firmware revision number:

Testing Agency Information State Contractor License: Tech License Number:

E-mail:

Fax:

x

3/12/2024 - 3/14/2024

USDA Forestry Science Lab 3200 SW Jefferson Wy Corvallis OR

USDA 541-750-7375

Commercial Contact Person: Phone Number:

E-Mail:

Monitoring Company Name:

Monitoring Company Phone:

Simplex 4100

Digital

1st Floor FACP Rm102

Testing Agency Name: Address:

Central Station Monitoring Yes Account Number:

Page: 2 Rev Date: 1/13/2023

System Power Nominal Voltage:

Amps:

Location:

Overcurrent Protection type:

Amps:

Disconnecting Means Location:

Secondary Power:

Type:

Location:

Battery Type (If Applicable):

Calculated capacity:

Standby Mode (Hours):

Alarm Mode (Minutes):

Notifications prior to Testing:

Monitoring Company Contact:

Time:

Building Management Contact:

Time:

Building Occupants Contact:

Time

AHJ

Contact:

Time

Other if required:

Control Unit and Related Equipment Visual Inspection:

Functional Test:

Control Unit Comments:

Lamps/LED’s/LCD’s Comments:

Fuses Comments:

Trouble Signals Comments:

Disconnect Switches Comments:

Ground-fault Monitoring Comments:

Supervision Comments:

Local annunciator Comments:

Remote annunciator Comments:

Remote power panels Comments:

Secondary Power Visual Inspection:

Functional Test:

by front door

6 RPS 2per Floor

120v Data Closet Rm 102.2 in front of panel breaker panel 1BA circuit 19

Battery In Panel

Sealed Lead Acid 12/35 x2 x x

X X x x

X x x x x x

Page: 3 Rev Date: 1/13/2023

Battery Condition Comments:

Load Voltage Comments:

Discharge Test Comments:

Remote panel batteries Comments:

Batteries marked with date of manufacturer Comments:

Alarm and Supervisory Alarm Initiating Device (Attach supplementary sheets)

Notification Appliances (Attach supplementary sheets)

Interface Equipment (Attach supplementary sheets)

Supervising Station Monitoring Yes: No:

Alarm Signal Comments (Including Time):

Alarm restoration Comments (Including Time):

Trouble signal Comments (Including Time):

Trouble restoration Comments (Including Time):

Supervisory Signal Comments (Including Time):

Supervisory Restoration Comments (Including Time):

Public Emergency Alarm Reporting System Yes: No:

Alarm Signal Comments (Including Time):

Alarm restoration Comments (Including Time):

Trouble signal Comments (Including Time):

Trouble restoration Comments (Including Time):

Supervisory Signal Comments (Including Time):

Supervisory Restoration Comments (Including Time):

Notifications that testing is Complete:

Monitoring Company Contact:

Building Management Contact:

X X

X X x x

X X

X

X x x x x

Page: 4 Rev Date: 1/13/2023

Time: Time:

Building Occupants Contact:

Time

AHJ

Contact:

Time

Other if required:

System restored to normal operation Date:

Time:

By:

System Certification Signed: Printed Name:

Organization: Title:

Phone: License # (with NICET or State License):

Wrap Up counts & Information System Devices Total Number of Units in

Building Total Number Units

Tested Test Results Acceptable

N/A YES NO

Bells, Horns & Chimes Voice Speakers (voice clarity) Operations Test

1. Smoke Detector

2. Duct Detector

Sensitivity Test

1. Smoke Detector

2. Duct Detector

Heat Detectors Sprinkler Flow Switches Sprinkler Supervisory Switches Visual Alarm Devices Manual Pull Stations Automatic Door Unlocks Automatic Door Release

Communication Equipment Total Number of Units in Building

Total Number Units Tested

Test Acceptable

N/A YES NO

Phone Sets Phone Jacks Call-in Signal

03/14/2024

0930 0930

65 65 x

221 X

10 x

19 x

5 x

4 x

98 x

29 x

1 x

Page: 5 Rev Date: 1/13/2023

SYSTEM FUNCTIONALITY YES NO

Number of stories?

Do all locking devices release upon activation of the fire alarm system?

Do all locking devices release upon power failure?

Does the door to roof unlock?

Do doors unlock but not unlatch?

Is there an access key at the control panel for doors that fail to unlock?

System Devices Total Number of Units in

Building

Total Number Units Tested Test Acceptable

N/A YES NO

Electric Strike

Electric Bolt

Other locking devices

Building is not equipped with Stairway Door Lock system.

Acceptance by Owner or Owner’s Representative:

Signed: Printed Name:

Date: Organization:

Title: Phone:

Problems Found:

X x x x x12

2nd Floor West NAC circuit NOT working, unable to access Rm 199.6 smoke detectors

1st Floor Central RPS batteries need replaced Room 112 does not exist, cant find devices Rm 214/193.2 cannot find devices

No access to Bldgs 400/500

Page: 6 Rev Date: 1/13/2023

Corrections Made:

3/18 accessed and tested Bldg 3000/4000 all devices passed

3/18 Replaced Batteries in RPS 1st floor Central

Page: 7 Rev Date: 1/13/2023

Notification Appliance Supplementary Record of Inspection & Testing

This form is supplemental to the system record of inspection & testing. This form is to be completed by the system inspection and testing contractor at the time of the inspection and/or test.

Inspection/Test Date & Time: ______________ Completed Date &Time: ___________

Number of supplementation pages Attached: _______

Property Information Name of Property:

Address:

Notification Appliance Test Results Appliance Type Location / Identifier: Pass Fail Other

Page: 8 Rev Date: 1/13/2023

Supplementary Record of Inspection & Testing (Continued)

Notification Appliance Test Results Appliance Type Location / Identifier: Pass Fail Other

Page: 9 Rev Date: 1/13/2023

Initiation Devices Supplementary Record of Inspection & Testing

This form is supplemental to the system record of inspection & testing. This form is to be completed by the system inspection and testing contractor at the time of the inspection and/or test.

Inspection/Test Date & Time: ______________ Completed Date &Time: ___________

Number of supplementation pages Attached: _______

Property Information Name of Property:

Address:

Initiating Device Test Results Device Type Location / Identifier & Address: Pass Fail Other

Page: 10 Rev Date: 1/13/2023

Supplementary Record of Inspection & Testing (Continued)

Initiating Device Test Results Device Type Location / Identifier & Address: Pass Fail Other