B08_Attachment_9_Ranger_Club_Report_0002.pdf

Dry Pipe Fire Sprinkler System

California Code of Regulations - Title 19 Inspection, Testing, and Maintenance

Quarterly and Annual Report 1 of 3

Property Information Contractor or Licensed Owner Information

Building Name Name

Address Address

City St. Zip

City License # Phone

Contact Person SFM Job # CSLB Misc.

Riser Information Main Drain Test (Annual) Riser No. Location Riser

Diameter Main Drain Diameter

Initial Static Pressure

Residual Pressure

Final Static Pressure P,F,N/A

This building has more than 5 risers. See additional AES 2.9 form attached Number of AES 2.9 forms attached:

Quarterly Inspections I = Inspection T = Test M = Maintenance P = Pass F = Fail N/A = Not Applicable

Item Description NFPA 25 CA ed.

Reference

Date Date Date Date

1.1 I Control Valves – Identification Sign 13.3.1

1.2 I Control Valves – Inspection 13.3.2

1.3 I Waterflow Alarm Devices 5.2.5

1.4 I Supervisory Devices 5.2.5

1.5 I Gauges (Dry Pipe Systems)

Pass = Normal Pressures

5.2.4.2, 5.2.4.3 5.2.4.4

13.4.4.1.2

1.6 I Air Pressure

5.2.4.2, 5.2.4.3

5.2.4.4 13.4.4.2.5.1 psi psi psi psi

1.7 I Water Supply Pressure

5.2.4.2

13.4.4.2.5.1 psi psi psi psi

1.8 I Hydraulic Design Information Sign

(for hydraulically designed systems) 5.2.6

1.9 I General Information Sign

(not required for system prior to 2007 edition of NFPA 13) 5.2.8

1.10 I Heat Tape 5.2.7

1.11 I Spare Sprinklers 5.2.1.4

1.12 I Fire Department Connections 13.7

1.13 I Dry Pipe Valves – Exterior Inspection 13.4.4.1.4

1.14 I Pressure Reducing Valves 13.5.1

1.15 Backflow Preventers 13.6.1

1.16 PRV – Fire Sprinkler Systems 13.5.1

Form AES 2.3 Sept. 3, 2013

Phone

California Code of Regulations - Title 19 Inspection, Testing, and Maintenance

Quarterly and Annual Report 2 of 3

Property Information Contractor or Licensed Owner Information

Building Name Name

Address Job #

City

ANNUAL INSPECTION, TESTING, AND MAINTENANCE

Include ALL Quarterly Inspections (See Previous Page)

I = Inspection T = Test M = Maintenance P = Pass F = Fail N/A = Not Applicable

Item Description NFPA 25 CA ed.

Reference Date Comments Only P,F,N/A

1.17 I Buildings (Freeze Protection) 4.1.1.1 Owner’s Responsibility

1.18 I Sprinklers 5.2.1

1.19 I Pipe and Fittings 5.2.2

1.20 I Hangers 5.2.3

1.21 I Seismic Braces 5.2.3

1.22 I Small Hose Connections* 13.5.6.2.2

2.1 T Field Service Test Required

(Send Report to Fire Code Official) 5.3.1 If REQUIRED, Enter 'F' until results are returned from Lab

2.2 T Recalled Sprinklers

If not present = Pass; If present = Fail

Title 19 904.1(c)

2.3 T Water Flow Alarm Devices

90 sec. maximum - (Enter Time )

5.3.3

13.2.6 sec.

2.4 T Main Drain Test

(Enter data on Page 1 of this form)

13.2.5 13.3.3.4

2.5 T Priming Water Level Test 13.4.4.2.1

2.6 T Dry Pipe Valve Trip Test

(Partial trip test is acceptable)

13.4.4.2.2 13.4.4.2.2.3 13.4.4.1.5

2.7 T Valve Trip Time 13.4.4.2.5.2 sec.

2.8 T Trip Air Pressure 13.4.4.2.5.1 psi

2.9 T Quick-Opening Device Test 13.4.4.2.4

2.10 T Low Air Pressure Alarm Test 13.4.4.2.6

2.11 T Low Temperature Alarm Test 13.4.4.2.7

2.12 T Automatic Air Pressure Maintenance Device Test 13.4.4.2.8

2.13 T Control Valve – Operation 13.3.3

2.14 T Valve Supervisory Devices 13.3.3.5

2.15 T Backflow Preventer Assemblies 13.6.2

2.16 T PRV – Partial Flow 13.5.1.3

* Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II, or III standpipe systems.

Form AES 2.3 Sept. 3, 2013

California Code of Regulations - Title 19 Inspection, Testing, and Maintenance

Quarterly and Annual Report 3 of 3

Property Information Contractor or Licensed Owner Information

Building Name Name

Address Job #

City

ANNUAL INSPECTION, TESTING, AND MAINTENANCE

Include ALL Quarterly Inspections (See Quarterly Inspections Page)

I = Inspection T = Test M = Maintenance P = Pass F = Fail N/A = Not Applicable

Item Description NFPA 25 CA ed.

Reference Date Comments Only P,F,N/A

3.1 M Control Valves 13.3.4

3.2 M Maintenance 13.4.4.3

3.3 M Dry Pipe Valve Interior Cleaned 13.4.4.3.1

3.4 M Low Points in System Drained 13.4.4.3.2

3.5 M Backflow Preventer 13.6.3

3.6 M

Obstruction Investigation Required (If “Yes”, see Deficiencies and Comments Section for Results.)

14.3 Yes No

3.7 M System Returned to Service 4.5.3

15.7

Yes No

D = Deficiency C = Comment (Indicate type )

Item Date Riser D C Deficiencies and Comments Indicate all equipment, devices and parts that were repaired or replaced

Check here if additional Deficiencies and Comments are listed on Form AES9

See Correction Form AES 10 for corrected deficiencies.

Number attached:

Number attached:

I hereby certify that the fire protection equipment listed above has been fully inspected, tested, and maintained on this date by the company indicated above, in accordance with CCR, Title 19, Sections 901 to 906 and that the equipment is fully operable except as noted in the “Deficiencies and Comments” section of this form.

Quarter

Check box if Annual Inspection, Testing & Maintenance Items are Completed in the Indicated Quarter Annual 4th Annual

Date

Print Name

Signature

Form AES 2.3 Sept. 3, 2013

Annual Annual 1st 2nd 3rd 4th lllllllllllllllllllllllllllllllllllllllllllllllllll