B08_Attach_1H_Structural_Fire_Inspection_and_Testing_Forms.pdf

Clean Agent or CO2 System Page 1 of 4 Revised 12/16/15

National Park Service / AKRO

Inspection and Test Report (complete a separate form for each system)

CLEAN AGENT OR CO2 SYSTEM – CLEAN AGENT CO2

Park Alpha Code: ______________________ FMSS Location No.:___________________

Location Description: ______________________

Date of Test:_________________________

Time:_________________

System Make: ______________________ System Model: _____________________

No of Cylinders ______________________ No. of Nozzles _____________________

Control Panel Make ______________________ Panel Model _____________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attach itemized sheet

REPAIRS: All deficiencies have been corrected N/A Yes No

This certifies that the fire and life safety system has been inspected and tested for functional operation in accordance with applicable NFPA standards, and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.

Technician Name (printed): ______________________ Company: ______________________________

Signature: ___________________________________ Phone #: _______________________________

State Certification No.: _________________________

National/NICET No.: ___________________________

ENCLOSURE INTEGRITY

1. After visual inspection, there are no unsealed penetrations in walls, ceiling, and floors that would affect enclosure integrity.

Yes No

2. Doors in the protected enclosure are self-closing and provided with sweeps/gaskets Yes No

3. HVAC penetrations in the protected enclosure that could affect agent hold time are provided with low-leakage dampers.

Yes No

NOZZLES, PIPING, AND HOSE

4. All nozzles, piping, and brackets are properly placed and are secured. Yes No

5. All hose was visually inspected and does not have visual defects. Yes No

6. All hose five years old and older has been tested in 5-year intervals in accordance with NFPA 2001 Section 7.3.2 Date for Next Hose Test:

CYLINDERS AND EXTINGUISHING AGENT

7. The quantity loss is <5% and the pressure loss is <10% in each cylinder from the required quantity and pressure of the extinguishing agent.

Yes No

8. There is an up-to-date log containing a record of semi-annual checks for the agent quantity and pressure on each cylinder

Yes No

9. All cylinders with an unacceptable quantity loss were refilled or replaced.

N/A Yes No

10. All cylinders are tested according to NFPA 2001 7.2.1 and 7.2.2 at the proper intervals. Date for next cylinder test________________

Clean Agent or CO2 System Page 2 of 4 Revised 12/16/15

DETECTION AND CONTROL

11. All detection/initiating devices respond properly when tested.

No. of Units Tested Manual Stations ________________ Smoke Detectors ________________ Heat Detectors ________________ Air Sampling Detectors ________________ Tamper Switches ________________ Other ________________

N/A Yes No

12. All alarm functions take place upon receipt of a signal from the detection devices.

N/A Yes No

13. All alerting / notification devices work properly.

No. of Units Tested Pre Discharge Devices ________________ Post Discharge Devices ________________

14. All supervised circuits send the proper signals to the control panel. N/A Yes No

15. All manual release stations are readily accessible, accurately identified, and properly protected to prevent damage.

RELEASE DEVICES

16. The automatic release device(s) work properly, including pre-discharge time delays.

17. All manual release stations used to release agents work properly. N/A Yes No

ABORT DEVICES

18. The manual abort switch is a dead-man type switch and functions properly.

AUXILIARY FUNCTIONS

19. All auxiliary functions such as alarm-sounding or displaying devices, remote annunciators, air-handling shutdown, damper operation, and power shutdown operate properly in accordance with system requirements and design specifications.

N/A Yes No

20. The alarms can be silenced, when allowed, without affecting other system functions.

SYSTEM MONITORING

21. The suppression control panel sends the proper signals to the building FACP.

N/A Yes No

22. The suppression control panel operates on standby power N/A Yes No

23. Signals were received at the monitoring company. N/A Yes No

TRAINING

24. All personnel working in enclosures protected by a clean agent system have received up-to-date training regarding clean agent safety issues.

Clean Agent or CO2 System Page 3 of 4 Revised 12/16/15

Type of Extinguishing Agent ___________________

Agent Cylinders #1 #2 #3 #4 #5

Serial No. __________ __________ __________ __________ __________

PSI __________ __________ __________ __________ __________

Gross Weight __________ __________ __________ __________ __________

Agent Weight __________ __________ __________ __________ __________

Tare Weight __________ __________ __________ __________ __________

Liquid Level __________ __________ __________ __________ __________

Hydro Date __________ __________ __________ __________ __________

Clean Agent or CO2 System Page 4 of 4 Revised 12/16/15

Deficiencies

Resolved

Location:

Deficiency:

Recommended Resolution:

NFPA reference:

Dry Chemical Suppression System Page 1 of 3 Revised 12/16/15

DRY CHEMICAL SUPPRESSION SYSTEM

No of Agent Cylinders ______________________ No. of Nozzles _____________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attach

This certifies that the fire and life safety system has been inspected and tested for functional operation in accordance with NFPA 17, and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.

Technician Name (printed): ______________________ Company: ______________________________

Signature: ___________________________________ Phone #: _______________________________

State Certification No.: _________________________ National/NICET No.: ______________________

COVERAGE , NOZZLES, AND PIPING

1. The area/hazard to be protected has the required number and type of nozzles to provide adequate fire protection.

Yes No

2. All nozzles are properly positioned. Yes No

3. Piping is installed and supported adequately with no evidence of damage Yes No

4. Fusible link cable conduits are immobilized with proper hangers and brackets. Yes No

SYSTEM CONTROLS

5. All system controls and components are accessible and free from obstructions. Yes No

6. The system is operational from the test link (last fusible link) Yes No

7. All fusible links have been replaced and the year of manufacture and date of installation is marked on the system inspection tag.

Yes No

8. Manual release station(s) are readily accessible, located 42” – 48” above the floor, and identify the hazard they protect

Yes No

9. Manual release stations are configured correctly and operational. Yes No

10. The operation of the fusible link line is not impaired by debris or foreign materials. Yes No

11. Where the system protects a hazard with flowing flammable or combustible fluids or gases, an automatic means to shutoff the fuel upon operation of the extinguishing system is provided.

N/A Yes No

12. Equipment and/or fuel shutoff interlock(s) were tested and are operational N/A Yes No

13. Warning signs are installed where there is a possibility that personnel could be exposed to a dry chemical discharge.

Dry Chemical Suppression System Page 2 of 3 Revised 12/16/15

14. The extinguishing agent in the cylinders conforms to the manufacturer’s requirements for this system.

Yes No

15. Storage cylinders are fastened securely to their mounting brackets. Yes No

16. The cylinders are filled with the correct volume of extinguishing agent.

Required volume ________lbs. or __________gals.

Yes No

17. The cylinder gauge is in the operational range. Yes No

18. The CO2 or Nitrogen cylinder is fully charged.

Design weight _____ lb. Actual Weight _____lb.

N/A Yes No

19. The hydrostatic testing of the agent cylinder(s) is up-to-date.

Date for next hydrostatic test ______________________

MONITORING

20. The system is connected to the fire alarm system. (if an alarm panel exists) N/A Yes No

21. The fire alarm panel receives the proper signals upon suppression system activation.

22. The alarm monitoring company received the alarm signal. N/A Yes No

Dry Chemical Suppression System Page 3 of 3 Revised 12/16/15

NFPA 17 reference:

Fire Alarm Page 1 of 3 Revised 12/16/15

FIRE ALARM SYSTEM – ADDRESSABLE CONVENTIONAL

Off Site Monitoring? Yes No Monitoring Company or Location

Name ________________________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attach

This certifies that the fire and life safety system has been inspected and tested for functional operation in accordance with the current edition of NFPA 72, and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.

Technician Name (printed): ______________________ Company: ______________________________

Signature: ___________________________________ Phone #: _______________________________

GENERAL

1. The key to the panel is available at the FACP. N/A Yes No

2. The operating instructions are available at the FACP. Yes No

3. Materials and equipment needed to restore pull stations are available at the main panel, e.g. glass rods, and plates; keys and allen wrenches, etc. N/A Yes No

FIRE ALARM CONTROL PANEL

4. All signals on the FACP operate on AC power. Yes No

5. All signals on the FACP operate on battery power. Yes No

6. All signals on the FACP operate on emergency generator/standby power N/A Yes No

7. A trouble signal activates upon loss of power, ground fault, and open circuit. Yes No

8. Circuit breaker location is identified at the FACP and all booster panels Yes No

INITIATING DEVICES AND NOTIFICATION APPLIANCES

9. All initiating and annunciating devices tested operate properly on AC power. Yes No

10. All initiating and annunciating devices tested operate properly on generator/standby power. Yes No

11. All initiating and annunciating devices tested operate properly on battery power. Yes No

12. 100% of the INITIATING DEVICES were tested per NFPA 72.

No. of Units Tested Manual Pull Stations ________________ Smoke Detectors ________________ Heat Detectors ________________ Sprinkler Waterflow ________________

Fire Alarm Page 2 of 3 Revised 12/16/15

Dry Sprinkler High/Low Air ________________ Duct Smoke Detectors ________________ Tamper Switches ________________ Suppression Systems ________________ Other ________________

13. 100% of the NOTIFICATION APPLIANCES were tested per NFPA 72

No. of Units Tested Horns ________________ Horn/Strobes ________________ Speakers ________________ Speaker / Strobes ________________ Bells (interior) ________________ Exterior Horns/Bells ________________

14. The audible alarm appliances tested operate at the levels designed by the manufacturer. Yes No

15. The audible appliances tested in residential areas generate a minimum of 70 dBA in sleeping areas.

16. The visual alarm appliances tested operate as designed. Yes No

BATTERIES

17. The batteries are rated for: ____ hours standby and ____ minutes alarm

18. Battery voltage (no load) ________ volts

19. Battery voltage (full load) ________ volts (signals operating)

20. Charge circuit voltage ________ volts

INTERFACE DEVICES

The FACP received signals from the following Interface devices: Tested by: Simulation Operation

21. Emergency Generator(s) N/A Yes No

22. Sprinkler Flow Switch(es) N/A Yes No

23. Supervisory Switch(es) N/A Yes No

24. Kitchen Hood Suppression System(s) N/A Yes No

25. Spray Booth Suppression System(s) N/A Yes No

26. Clean Agent System(s) N/A Yes No

27. Fire Pump(s) N/A Yes No

28. Other - N/A Yes No

OTHER EQUIPMENT CONTROLLED BY FACP

The following Fire Safety Functions responded to signals from the FACP. Tested by Simulation Operation

29. Fan controls N/A Yes No

30. Smoke Dampers N/A Yes No

31. Elevator Recall N/A Yes No

32. Elevator Shunt Trip N/A Yes No

33. Door hold release N/A Yes No

34. Fire Pump(s) N/A Yes No

35. Remote Annunciator Panels N/A Yes No

36. Other - N/A Yes No

37. Signals were received at the monitoring company or approved location. N/A Yes No

Fire Alarm Page 3 of 3 Revised 12/16/15

NFPA 72 reference:

Fire Pump System Page 1 of 3 Revised 12/16/15

FIRE PUMP SYSTEM – RESIDENTIAL PUMP COMMERCIAL PUMP

Pump Make: ______________________ Pump Model / SN: _____________________________

Controller Make ______________________ Controller Model / SN _____________________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attach

This certifies that the fire and life safety system has been inspected and tested for functional operation in accordance with applicable NFPA 20 and NFPA 25 standards, and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.

Technician Name (printed): ______________________ Company: ______________________________

Signature: ___________________________________ Phone #: _______________________________

WATER STORAGE TANK

1. Water level is within normal range Yes No

2. Heating system is functional N/A Yes No

3. Exterior inspection of tank structure, supports, vents, and outlets, shows no evidence of accelerated corrosion or damage.

Yes No

4. Interior inspection was performed and shows no evidence accelerated corrosion, pitting, debris, or biological growth. (required at 5 year intervals)

N/A Yes No

5. Supply valve to fire pump is open Yes No

6. Automatic fill piping valves are open and operational N/A Yes No

ELECTRIC DRIVEN PUMP

7. The pump was started automatically by inducing a drop in pressure Yes No

8. Pressure readings during a no-flow (churn) condition.

Suction PSI: ______ Discharge PSI: _______

Yes No

9. Adjust pump packing glands as necessary for slight discharge Yes No

10. The pump casing relief valve operates properly Yes No

11. Check packing boxes, bearing, or pump casing for overheating Yes No

12. The electric pump ran properly for a minimum 10 minutes. Yes No

Fire Pump System Page 2 of 3 Revised 12/16/15

DIESEL DRIVEN PUMP

13. The pump was started automatically by inducing a drop in pressure Yes No

14. Pressure readings during a no-flow (churn) condition.

Suction PSI: ______ Discharge PSI: _______

Yes No

15. Adjust pump packing glands as necessary for slight discharge Yes No

16. The pump casing relief valve operates properly Yes No

17. Check packing boxes, bearing, or pump casing for overheating Yes No

18. Fuel level is at least 2/3 full. Yes No

19. Oil level is within acceptable range. Yes No

20. Batteries voltage reading are within acceptable range Yes No

21. The fuel filter/strainer has been serviced. Yes No

22. The diesel pump ran properly for a minimum 30 minutes. Yes No

PUMP CONTROLLERS

23. A pump controller regulates a commercial fire pump and is UL listed and operates per NFPA 20

N/A Yes No

24. A pump controller regulates a jockey pump and operates as required by

NFPA 20

N/A Yes No

25. A pump controller regulates a residential-type pump and operates as required by NFPA 20

FLOW TEST - RATED CAPACITY (GPM) ________ RATED SPEED (RPM) ________ RATED PRESSURE (PSI) _________

26. An annual flow test was performed per NFPA 20 at minimum, rated, and peak flows through approved test devices

N/A Yes No

27. The pump runs smoothly without unusual noise or vibration throughout the test. Yes No

28. The gauges passed a 5-year pressure gauge comparison test with a calibrated gauge.

Date for next test:______________

Yes No

29. Defective gauges have been replaced or recalibrated. N/A Yes No

30. The pump performs at its rated capacity and at 150% of its rated capacity (or the maximum capacity the water supply will accommodate)

Yes No

31. Flow readings measured:

Churn (no flow): ______ gpm Rated Capacity: _____ gpm 150% Rated Capacity: _____ gpm

32. Pressure readings - Discharge Gauge Churn (no flow): _______ psi Rated Capacity: _____ psi 150% Rated Capacity: _____ psi

33. Pressure readings – Suction Gauge:

Churn (no flow): _______ psi Rated Capacity: _____ psi 150% Rated Capacity: _____ psi

34. Flow Test device used: Hoses and Pitot Tube FM flowmeter Diffuser/Hosemonster

TRANSFER SWITCH

35. A simulated power failure during peak flow automatically activated the transfer switch within 10 seconds.

N/A Yes No

36. After the automatic connection was made to an alternate power source;

peak flow was redelivered within 30 seconds.

N/A Yes No

37. The manual emergency transfer equipment operated properly during peak flow and peak flow was redelivered within 30 seconds.

SYSTEM MONITORING

38. The pump controller panel sends the proper signals to the building

FACP.

N/A Yes No

39. The suppression control panel operates on standby power N/A Yes No

40. Signals were received at the monitoring company. N/A Yes No

Fire Pump System Page 3 of 3 Revised 12/16/15

NFPA 20 or NFPA 25 reference:

Fire Sprinklers Page 1 of 4 Revised 1/14/16

FIRE SPRINKLER SYSTEM – DRY PIPE WET PIPE PREACTION RESIDENTIAL

Riser Valve Make: ______________________ Valve Model: _____________________ Size: ____________________ Serial No: _____________________

Backflow Make: ______________________ Backflow Model: _____________________ Size: ____________________ Serial No: _____________________

Off Site Monitoring? Yes No Monitoring Company or Location

Name ________________________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attach

This certifies that the fire and life safety system has been inspected and tested for functional operation in accordance with the current edition of NFPA 25 and NFPA 13, and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.

Technician Name (printed): ______________________ Company: ______________________________

Signature: ___________________________________ Phone #: _______________________________

GENERAL

1. Sprinkler coverage was inspected and is adequate Yes No

2. Sprinkler heads are not blocked or obstructed Yes No

3. Piping is adequately installed with no bent or visibly damaged piping Yes No

4. Hangars and bracing components are not missing or damaged Yes No

5. A backflow preventer is provided and is accessible for maintenance N/A Yes No

6. Sprinkler heads are provided 18” min. clearance above top of storage N/A Yes No

7. Hydraulic design placard is installed and visible on riser N/A Yes No

SPRINKLER HEADS

8. Number of Sprinkler Heads: <20 >20 but < 100 >100

9. All accessible sprinkler heads have been visually inspected and are free of corrosion, paint, obstructions and/or physical damage. (If “no”, list the location of any defective heads in the “Deficiencies” section.)

Yes No

10. Standard Response sprinkler heads are less than 50 years old and do not require sample testing or replacement.

N/A Yes No

11. Fast Response sprinkler heads (quick response and residential) are less than 20 years old and do not require sample testing or replacement.

Fire Sprinklers Page 2 of 4 Revised 1/14/16

12. Dry type sprinkler heads are less than 10 years old and do not require sample testing or replacement

N/A Yes No

13. The proper number of spare sprinkler heads is available, with the proper wrenches for each, at the riser or another designated location.

FLOW TESTS

14. The system main drain is the proper size and discharges to the exterior of the building.

Size of drain _______ Required size ________

Yes No

15. A Main Drain flow test was performed:

Static pressure ____ psi Flow pressure ____ psi Return to static pressure ____min/sec

16. Flow from the inspector’s test valve activates the system alarms within 60 seconds. Yes No

ALARMS AND SUPERVISORY DEVICES

17. All supervisory and alarm devices [i.e. bell(s), flow switches, high/low air switches, valve tamper switches] function properly.

18. A water motor gong/bell is provided on the exterior of the building N/A Yes No

VALVES

19. All system supply and control valves are secured or supervised in the open position. Yes No

20. All supply valves have been lubricated (OS&Y valves) N/A Yes No

GAUGES

21. The maintenance on system gauges is up-to-date. Every 5 years, installed gauges shall be checked against (1) calibrated gauge to determine accuracy. If not within 3% of the calibrated gauge it should be replaced or recalibrated.

Due date for the next comparison test: ____________

OBSTRUCTION INVESTIGATION

22. A 5-year obstruction investigation was performed per NFPA 25.

Date for next obstruction investigation _____________

FIRE DEPARTMENT CONNECTIONS

23. The Fire Department Connection(s) (FDC) is clear of bushes, guards, or other debris and is visible from the fire access road

N/A Yes No

24. FDC inlets have protective caps or covers. (Note: If missing, the pipe shall be visually inspected for debris)

25. FDC inlets have at least 12” clearance for operating wrenches. N/A Yes No

ALARM MONITORING

26. All signals were received by the fire alarm system and the monitoring company.

DRY PIPE SYSTEM

27. The dry pipe valve was trip tested per NFPA 25. System tripped at _______ psi.

N/A Yes No

28. Water was discharged from the inspector’s test connection within 60 seconds of opening the test valve. Water delivery was _______ seconds.

N/A Yes No

29. Air compressor refills system in 30 minutes or less. N/A Yes No

30. The system’s low points were drained and the system was restored to service.

31. A quick opening device (QOD) is used (accelerator or exhauster) N/A Yes No

PREACTION SYSTEM

32. Heat actuation devices were functionally tested. N/A Yes No

Fire Sprinklers Page 3 of 4 Revised 1/14/16

ANTIFREEZE

33. Antifreeze solution has been inspected and checked N/A Yes No

34. Premixed antifreeze solution is used N/A Yes No

PRESSURIZED WATER STORAGE TANK

35. Water level is within the normal range Yes No

36. Heating system is functional N/A Yes No

37. Exterior inspection of tank structure, supports, vents, and outlets, shows no evidence of accelerated corrosion or damage.

Yes No

38. Interior inspection was performed and shows no evidence accelerated corrosion, pitting, debris, or biological growth. (required at 3 year intervals)

N/A Yes No

39. All supply valves are open Yes No

40. Air or nitrogen pressure and quantity is adequate N/A Yes No

RECALLS

41. The technician did not find recalled devices or equipment during the visual inspection.

Fire Sprinklers Page 4 of 4 Revised 1/14/16

NFPA 25 or NFPA 13 reference:

Kitchen Suppression System Page 1 of 3 Revised 12/21/2015

KITCHEN SUPPRESSION SYSTEM – DRY CHEMICAL WET CHEMICAL

No of Agent Cylinders ______________________ No. Appliance Nozzles _____________________

No. Plenum Nozzles: ______________________ No. of Duct Nozzles _____________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attach

This certifies that the fire and life safety system has been inspected and tested for functional operation in accordance with NFPA 96, and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.

Technician Name (printed): ______________________ Company: ______________________________

Signature: ___________________________________ Phone #: _______________________________

APPLIANCE COVERAGE , NOZZLES, AND PIPING

1. All cooking appliances that can produce grease laden vapors are completely under the range hood.

Yes No

2. All cooking appliances have the required number and type of nozzles to provide adequate fire protection.

Yes No

3. All nozzles are properly positioned. Yes No

4. Nozzle protective covers are in place. Yes No

5. Multiple hoods installed end to end, back to back, or sharing common ductwork are configured as a single hazard area with simultaneous operation.

Yes No

6. All piping and releasing cable conduit are immobilized with proper hangers and brackets. Yes No

7. The manual (remote) pull station is located 10 - 20 feet from the protected appliances in the path of egress and 42” – 48” above the floor.

SYSTEM CONTROLS

8. All system controls and components are accessible and free from obstructions. Yes No

9. The system is operational from the test link (last fusible link) Yes No

10. All fusible links have been replaced and the year of manufacture and date of installation is marked on the system inspection tag.

Kitchen Suppression System Page 2 of 3 Revised 12/21/2015

11. The manual (remote) pull is configured correctly and is operational. Yes No

12. The operation of the fusible link line is not impaired by grease. Yes No

13. The micro switch that controls shutoff of gas and/or electrical power to the appliances functions properly.

Yes No

14. The gas shuts down upon system activation. N/A Yes No

15. The appliance electrical shutdown device functions properly. N/A Yes No

16. The extinguishing agent in the cylinders conforms to the manufacturer’s requirements for this system.

Yes No

17. The system has adequate supply of extinguishing agent as required to meet the demand for complete coverage of the cooking appliances.

Yes No

18. The cylinders are filled with the correct volume of extinguishing agent.

Required volume ________lbs. or __________gals.

Yes No

19. The cylinder gauge is in the operational range. Yes No

20. The CO2 or Nitrogen cylinder is fully charged.

Design weight _____ lb. Actual Weight _____lb.

Yes No

21. The hydrostatic testing of the agent cylinder(s) is up-to-date.

Date for next hydrostatic test ______________________

22. The system is connected to the fire alarm system. (if an alarm panel exists) N/A Yes No

23. The fire alarm panel receives the proper signals upon suppression system activation.

24. The alarm monitoring company received the alarm signal. N/A Yes No

CLEANING

25. The surfaces around the cooking surfaces, range hood, and ducting from hood to termination are free of grease deposits.

Kitchen Suppression System Page 3 of 3 Revised 12/21/2015

NFPA 96 reference:

Backflow Preventer Device Page 1 of 2 Revised 2/24/17

Inspection and Test Report (complete a separate form for each system)

BACKFLOW PREVENTION DEVICE

Park Alpha Code:_____________________ FMSS Location No.: _____________________

Location Description: _________________________________________________________

Date of Test: _________________________________ Time: _____________________

Location: Inside Outside Above Ground Pit

Usage: Fire Domestic Irrigation

Type of Device: RP DC DCDA RPDA

Manufacturer: ___________________________ Model No.: ______________________________

Size: ___________________________________ Serial No.: _______________________________

Orientation: Vert Up Vert Down Horizontal Height off Floor: ___________( in/ft)

REDUCED PRESSURE PRINCIPAL ASSEMBLE

*Relief ports on RPZ free of continuous discharge? Yes No

Date Installed:

DOUBLE CHECK VALVE ASSEMBLY

Apparent Pressure Drop

Across First Check

Valve________

Date Rebuilt:

Check Valve #1 Check Valve #2 Relief Valve PVB / SVB

Held at _______PSID

Leaked

Held at _______PSID

Closed Tight

Leaked

Opened at _______PSID

Did not open

AIR INLET

Opened at _______PSID

Did not open

Cleaned

Replaced

Cleaned

Replaced

Cleaned

Replaced

Cleaned

Replaced

________ PSID

Closed Tight

________ PSID Air Inlet _______PSID

Check Valve _______PSID

Leaked

________ PSID

F

IN

A L

R

E P

A

IR

S M

A D

E

IN

IT

IA

L

PASS FAIL No. 2 Shutoff Valve

Closed Tight

Leaked

Supply Pressure ___________

Backflow Preventer Device Page 2 of 2 Revised 2/24/17

Test Kit Manufacturer: __________________ Model: ______________________________

Serial No.: _______________________________ Last Calibration Date: _________________

Certified Tester: _________________________ Certified Tester No.: __________________

Signature: ______________________________________________________________________

FORWARD FLOW TEST—Required by NPS for all backflow preventers where fire sprinkler systems are located downstream of the backflow preventer. The test shall include forward flow test of the system at the designed flow rate, including hose stream demand. For back-flow preventers sized 2 inches and less, forward flow test shall be acceptable to conduct without measuring flow, where the test outlet is a size to flow the system demand.

Forward Flow Test Performed: Yes No

Design Flow Rate: __________________ GPM Actual Flow Rate: ______________ GPM

If not tested, Why:

DEFICIENCIES

Resolved

Location: _____________________________________________________________________

Deficiency: ___________________________________________________________________

Recommended Resolution: _____________________________________________________

Resolved

Location: _____________________________________________________________________

Deficiency: ___________________________________________________________________

Recommended Resolution: _____________________________________________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attached itemized sheet.

REPAIRS: All deficiencies have been corrected: N/A Yes No

Backflow Prevention Device Testing JAS