2PG SS FM200 (AS)(D).pdf

Customer: Date of Service:

Inspector: SR#:

Task#:

# Cylinder type Cylinder Mfr.

Serial

Number Last Test

Date Stamped Wt. (A)

Total Wt. (B) Cylinder Fill / Capacity (A-

B)

Cylinder Pressure

Condition Liquid Level

Indicator Temperature

Last 5 Yr.

External

Inspection Date

Rack #

1 4BW450 FIKE 1363255 10/21/2019 320 147 320 390 GOOD 11" 72 1/21/2020

Scott Reed, Dalton Allison

Print Name:

3/26/2021

Inspector Name (Print):

Waren H. Shipley

3/26/2021

Signature:

emailed to Scott.Reed@va.gov, Dalton.Allison@va.gov

IMPORTANT NOTICE TO CUSTOMER: Customer acknowledges and agrees that, in the absence of a Service Agreement between parties, services hereunder are performed pursuant to the terms and conditions on the reverse side of this Inspection Report. Customer further agrees that the services have been completed to Customer's satisfaction and that the system is in good working order and repair, unless services performed were of a temporary nature, in which case Customer acknowledges that part of customer's system may have been bypassed or is otherwise inoperable until services can be completed. CUSTOMER'S ATTENTION IS DIRECTED TO THE LIMITATION OF LIABILITY, WARRANTY, INDEMNITY AND OTHER CONDITIONS ON THE REVERSE SIDE.

Acceptance of customer or customer's representative

Date:Inspector Signature:Date:

15. Deficiencies and Recommendations were discussed with Customer / Customer Representative:

If No, explain:

Manual Pull Station Release is missing 'Suppression Release' label

14. Deficiencies and Recommendations:

Address

City, State Zip

Phone#

Special Hazards Inspection Report Johnson Controls Fire Protection LP

See photos.

3/26/21

48545126

75891089 Warren H. Shipley

VA - Lake Nona - Superstructure - Room 4K907

12. Cylinder Inspection

Cylinder Inspection Comments:

13. List Changes in Occupancy, Hazard, or Fire Protection System in Section 2:

Yes No N/A jshiplw Highlight jshiplw Highlight