Latest Report Redacted.pdf

INSPECTION DATE _____________________

NAME ____________________________________________________________________

ADDRESS _________________________________________________________________

CITY ___________________________________ STATE _____________________________

OWNER or MANAGER ________________________________________________________

TELEPHONE NO. ____________________________________________________________

WORK ORDER NO. __________________________________________________________

Du t Size _____________________________ Plenum Size _____________________________ ilter Size _____________________________

Cooking Appliances Left to Right ________________________________________________________________________________________________________________________ NFPA 96 2008 .12. 1. 2.2 Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior revaluation of the fire- extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system.

Client’s Authorized Agent

Canary (Forwarded to AHJ per NFPA 96 11.2.8) Pink (Client)

SEMI- ANNUAL RECHARGE

AMEREX ANSUL ANSUL PIRANHA KIDDE

PYRO-CHEM RANGE GUARD OTHER _________________________

SINGLE DOUBLE TRIPLE

MODEL NO. & TYPE _______________FLOW POINTS-AVAIL ________

LOCATION OF SYSTEM ______________ _

System interlocked with building fire alarm System discharged All seals intact, no evidence of tampering All appliances properly covered w/correct nozzles Duct & plenum covered w/ co nozzles Check positioning of all nozzles Hood/ uct penetrations sealed

8. Grease accumulation Light

Exhaust last clean date _______________ CO: _______________ Pressure gauge in proper range

11. Cylinder hydrostatic test date ___________ Ht ___________ Mfg. ___________ Checked cartridge: Weight ___________ HT ___________ Inspect cylinder and mount Operated system from terminal link Checked travel of cable and link position Replaced fusible links mfg. date _______________

165°___________ 212° ___________ 280°___________ 360° ___________ 450°___________ 500°___________

Fusible link type damper serviced. Qty Check operation of remote manual release Proper location of remote manual release Checked operation of micro-switch Checked operation of mechanical gas valve Checked operation of electric gas valve Properly functioning reset relay Relight pilots

Note: Non compliance systems may fail to extinguish/suppress a

Piping/conduit securely bracketed System piping clear of obstruction Nozzles cleaned Proper nozzle caps/covers in place Proper clearance flame to filters (18” min.)

Proper separation between fryers & open flame Exhaust fan in operating order Remote manual release seals in place System cartridge replaced/safety pins removed System operational and armed Fan warning sign on hoo K class fire extinguisher in cooking area 2A water type or wet chemical ext. for solid fuel 4A rated fire extinguisher (kitchen) Proper ABC fire extinguisher for other areas Fire extinguishers properly serviced Personnel instructed in manual operation of system Personnel instructed on required monthly insp. f sys Personnel instructed on use of fire extinguishers Service and certification tag on system

System installed per U.L. 300 standard & meets

Manufacturers U.L. listing System complies w/NFPA 96/17A standards Client verbally advised of deficiencies Client has given consent to make corrections

Yes No N/A Yes No N/A

Comments/Non Compliance

Date Time AM PM

8/28/25

VA MEDICAL CENTER ■

913 NW GARDEN VALLEY BLVD ■

ROSEBURG OR Regulator test 2/6/25

(541) 440-1000 R-102 911

41375784 Canteen

Aug. 2025 State wide

X2025

47.0 2025

✔ ✔2024

System cartridge was light replaced with new warranty cartridge. System passed inspection

14 x14 10 Na wash hood

6 burner / griddle / fryer

8/28/25 2:00 ✔

Customer Name: ______________________________________________________

Address: _____________________________________________________________

Date of Inspection: ____________________________________________________

The Quencher Water Spray Fire Protection System is installed in accordance with the Manufacturer’s instruction, NFPA standards 96 &13.

Inspection performed by: _________________

Date: ________________________________________________________________

1. SERIAL Number: ______________________________

2. Model # of System: ____________________________

3. Pipe Size: ____________________________________

4. Number of Nozzles on System: ___________________

5. Check Location of Nozzles against shop drawings and /or Quencher

Installation manual

Acceptable Not Acceptable

6. Type of Cooking Equipment

Gas Electric Soiled Fuel Other

7. Type of Ventilator:

Water Wash Non Water Wash

1. With hand valve in open position, check to be sure green light is on.

2. Water pressure

On drawings.

3. Close hand valve. Green light should go off

4. Amber light should be flashing.

5. Reopen hand valve. Reset light should be on

6. Push reset button. Green light should be on ; reset light and flashing amber

Light off

1. Fully open bypass test valve located on ventilator.

The following should occur:

a. Water flows out bypass test pipe.

b. Fire alert alarm is activated.

c. Fire indicator light flasher

d. Cooking equipment shut off.

Turn off bypass test valve

Push reset button to return system to normal operation

Re-light pilots if gas equipment, and /or res t shunt trip breaker, if shunt trips are used.

Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

VA MEDICAL CENTER building 81

913 NW GARDEN VALLEY BLVD ROSEBURG OR 97471-6523

8/28/25

8/28/25

N/A

AVTECH

1.5

80 ps

Hood not in use system power was off. Visual inspection only function test could not be done

Yes No

R

VENTILATOR START–UP INSPECTION for Model CG3 / GX 2 / CG / RG / FX Series Ventilators

Customer Name ______________________________________________________________________________________________________

Address _____________________________________________________________________________________________________________

City _______________________________________________________ State _____________________________ Zip ____________________

Date ______________________________________________________

MAKE-UP AIR

Kitchen make-up air supply is turned on Type of make up air

Ceiling Registers Built into Hood Ceiling Linear Diffusers Other

3. If ceiling register or linear diffusers, approximate distance from face of hood

Model of Control Cabinet __________________________________________________________________

Push “START WASH’ on Control Cabinet. Check the following:

A. Exhaust fan off B. Damper closes to the front of the hood C. Water turned on D. All nozzles spraying E. Wash light is on F. Detergent pump operating

Length of wash cycle Minutes Length of cleaning cycle changed to ______________________________________________________ Water pressure ____________________ PSI Water temperature ____________________ F°

K. Any ventilator leaks L. Drains free and clear M. Brand of detergent used ________________________________________________________________ N. Open inspection doors and check grease build-up in ventilation chamber.

None Slight Moderate Heavy O. Check grease build-up on damper face and canopy surfaces.

None Slight Moderate Heavy P. Ventilator cleaning system Has Has not been maintained properly Recommend ventilator be steam cleaned or pressure washed.

AIR VOLUME READINGS

Push “Start Fan” and take velocities. Record as follows: Exhaust record in the “EX” row. Exhaust at Custom Air baffles (if applicable) record in the “CA” row, and Make-up Air record in the “MA” row.

Yes No

Yes No

Yes No Yes No

Yes No Yes No

Yes No

EX

CA

MA

EX

CA

MA

AIR VELOCITIES (FPM) FROM LEFT TO RIGHT HOOD

SLOT, FILTER BAND OR MAKE-UP AIR DISCHARGE ITEM NO. HOOD SERIAL NO. AVERAGE

WASH MODE TEST:

1.

2.

Yes No Yes No

At the conclusion of check A through P above, push the “CANCEL” button inside the electrical compartment. Check the following:

A. Did the water shut off Yes No B. Did the damper stay closed Yes No

3.

VA MEDICAL CENTER. Canteen

913 NW GARDEN VALLEY BLVD

ROSEBURG OR 97471-6523

8/28/25

1 Na 865

GPC 6000

Na

? Broken needle

G510

1. Damper closed to rear

2. Water Turned on

3. Exhaust fan shut off

4. Fire indicating light on

Upon completion of the thermostat test push the “CANCEL” button on the command center. The following should occur” A. Water shut off B. Damper remains closed C. Fire indicating light turned off

REMOTE FIRE SWITCH TEST (Optional Equipment): Equipped Not Equipped Open fire switch and flip toggle switch to the “ALARM” or “TEST” position. The following should occur:

1. Water spray turned on

2. Damper remained open

3. Fan remained on (or turned on)

4. Fire indicating light on NOTE: Water will continue to run for 5 minutes after the switch has been pushed back to the normal position. The water may be shut off prior to the end of the cool down cycle by pushing the “CANCEL” button on the command center.

FIRE DAMPER INFORMATION

Ventilator has electric damper Ventilator has fuse link damper Ventilator does not have fire damper Number of fuse link dampers __________________________ Number 280° fusible links _____________________________

INSTALLATION INCLUDES THE FOLLOWING:

Gaylord Heat Reclaim Unit (HRU) Gaylord Distributor (UDS) Gaylord Recirculating Wash System (GRW) The Gaylord “Quencher” Fire Protection System Wet Chemical Fire Protection System

Date

Fire Mode Test:

CAUTION: Before any fire test are performed, check with building superintendent to see if Gaylord control cabinet is tied into building alarm, monitoring system and/or Fire Department.

Is System intertied with building alarm monitoring system/Fire Department? Yes No

THERMOSTAT TEST

With the exhaust fan on, open electrical compartment on Control Cabinet and push the “Fire Test Switch”.

The following should occur:

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No

Yes No Yes No

Yes No Yes No

Personnel provided with ventilator technical manual Yes No

Inspection Witnessed by (Print Name) _ _____________________________________________________________

Push “START FAN”. Check the following:

A. Fan on light comes on Yes No B. Damper fully opens after approx. 30 seconds Yes No

4.

8/28/25

Gauge psi needle is broken needs replaced and needs a new check valve will send quote

Yes No

R

VENTILATOR START–UP INSPECTION for Model CG3 / GX 2 / CG / RG / FX Series Ventilators

Customer Name ______________________________________________________________________________________________________

Address _____________________________________________________________________________________________________________

City _______________________________________________________ State _____________________________ Zip ____________________

Date ______________________________________________________

MAKE-UP AIR

Kitchen make-up air supply is turned on Type of make up air

Ceiling Registers Built into Hood Ceiling Linear Diffusers Other

3. If ceiling register or linear diffusers, approximate distance from face of hood

Model of Control Cabinet __________________________________________________________________

Push “START WASH’ on Control Cabinet. Check the following:

A. Exhaust fan off B. Damper closes to the front of the hood C. Water turned on D. All nozzles spraying E. Wash light is on F. Detergent pump operating

Length of wash cycle Minutes Length of cleaning cycle changed to ______________________________________________________ Water pressure ____________________ PSI Water temperature ____________________ F°

K. Any ventilator leaks L. Drains free and clear M. Brand of detergent used ________________________________________________________________ N. Open inspection doors and check grease build-up in ventilation chamber.

None Slight Moderate Heavy O. Check grease build-up on damper face and canopy surfaces.

None Slight Moderate Heavy P. Ventilator cleaning system Has Has not been maintained properly Recommend ventilator be steam cleaned or pressure washed.

AIR VOLUME READINGS

Push “Start Fan” and take velocities. Record as follows: Exhaust record in the “EX” row. Exhaust at Custom Air baffles (if applicable) record in the “CA” row, and Make-up Air record in the “MA” row.

Yes No

Yes No

Yes No Yes No

Yes No Yes No

Yes No

EX

CA

MA

EX

CA

MA

AIR VELOCITIES (FPM) FROM LEFT TO RIGHT HOOD

SLOT, FILTER BAND OR MAKE-UP AIR DISCHARGE ITEM NO. HOOD SERIAL NO. AVERAGE

WASH MODE TEST:

1.

2.

Yes No Yes No

At the conclusion of check A through P above, push the “CANCEL” button inside the electrical compartment. Check the following:

A. Did the water shut off Yes No B. Did the damper stay closed Yes No

3.

VA MEDICAL CENTER. Main hood

913 NW GARDEN VALLEY BLVD

ROSEBURG OR 97471-6523

8/28/25

C 4000

Na

G510

1. Damper closed to rear

2. Water Turned on

3. Exhaust fan shut off

4. Fire indicating light on

Upon completion of the thermostat test push the “CANCEL” button on the command center. The following should occur” A. Water shut off B. Damper remains closed C. Fire indicating light turned off

REMOTE FIRE SWITCH TEST (Optional Equipment): Equipped Not Equipped Open fire switch and flip toggle switch to the “ALARM” or “TEST” position. The following should occur:

1. Water spray turned on

2. Damper remained open

3. Fan remained on (or turned on)

4. Fire indicating light on NOTE: Water will continue to run for 5 minutes after the switch has been pushed back to the normal position. The water may be shut off prior to the end of the cool down cycle by pushing the “CANCEL” button on the command center.

FIRE DAMPER INFORMATION

Ventilator has electric damper Ventilator has fuse link damper Ventilator does not have fire damper Number of fuse link dampers __________________________ Number 280° fusible links _____________________________

INSTALLATION INCLUDES THE FOLLOWING:

Gaylord Heat Reclaim Unit (HRU) Gaylord Distributor (UDS) Gaylord Recirculating Wash System (GRW) The Gaylord “Quencher” Fire Protection System Wet Chemical Fire Protection System

Date

Fire Mode Test:

CAUTION: Before any fire test are performed, check with building superintendent to see if Gaylord control cabinet is tied into building alarm, monitoring system and/or Fire Department.

Is System intertied with building alarm monitoring system/Fire Department? Yes No

THERMOSTAT TEST

With the exhaust fan on, open electrical compartment on Control Cabinet and push the “Fire Test Switch”.

The following should occur:

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No

Yes No Yes No

Yes No Yes No

Personnel provided with ventilator technical manual Yes No

Inspection Witnessed by (Print Name) _________________________________________________________________

Push “START FAN”. Check the following:

A. Fan on light comes on Yes No B. Damper fully opens after approx. 30 seconds Yes No

4.

8/28/25

Customer Name: ______________________________________________________

Address: _____________________________________________________________

Date of Inspection: ____________________________________________________

The Quencher Water Spray Fire Protection System is installed in accordance with the Manufacturer’s instruction, NFPA standards 96 &13.

Inspection performed by: _________________

Date: ________________________________________________________________

1. SERIAL Number: ______________________________

2. Model # of System: ____________________________

3. Pipe Size: ____________________________________

4. Number of Nozzles on System: ___________________

5. Check Location of Nozzles against shop drawings and /or Quencher

Installation manual

Acceptable Not Acceptable

6. Type of Cooking Equipment

Gas Electric Soiled Fuel Other

7. Type of Ventilator:

Water Wash Non Water Wash

1. With hand valve in open position, check to be sure green light is on.

2. Water pressure

On drawings.

3. Close hand valve. Green light should go off

4. Amber light should be flashing.

5. Reopen hand valve. Reset light should be on

6. Push reset button. Green light should be on ; reset light and flashing amber

Light off

1. Fully open bypass test valve located on ventilator.

The following should occur:

a. Water flows out bypass test pipe.

b. Fire alert alarm is activated.

c. Fire indicator light flasher

d. Cooking equipment shut off.

Turn off bypass test valve

Push reset button to return system to normal operation

Re-light pilots if gas equipment, and /or res t shunt trip breaker, if shunt trips are used.

Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

VA MEDICAL CENTER main hood

913 NW GARDEN VALLEY BLVD ROSEBURG OR 97471-6523

8/28/25

8/28/25

35c3 1.25-12

1 1/4

Electricity to appliances not shutting down. Electricity needs to shut off at time of trip. Recommend a replacement to a wet chemical fire system. System test pipe work has a crack in an elbow leaks during testing on top of hood