36C26118Q0577-0005003.pdf

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Wet 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

Initial Static Pressure

Residual

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 (Wet Pipe Systems) 5.2.4.1

1.6 I Enter Water Supply Pressure Below Riser Check 5.2.4.1 psi psi psi psi

1.7 I Enter Water Supply Pressure Above Riser Check 5.2.4.1 psi psi psi psi

1.8 I Pressure Readings Acceptable 5.2.4.1

1.9 I Hydraulic Design Information Sign

(for hydraulically designed systems) 5.2.6

1.10 I General Information Sign

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

1.11 I Heat Tape 5.2.7

1.12 I Spare Sprinklers 5.2.1.4

1.13 I Fire Department Connections 13.7

1.14 I Alarm Valves – Exterior Inspection 13.4.1

1.15 I Pressure Reducing Valves 13.5.1.1

1.16 I Backflow Preventers 13.6.1

1.17 I Small Hose Connections - Hose Valve* 5.1.6, 13.5.2

13.5.5.1

1.18 I PRV – Fire Sprinkler Systems 13.5.1.1

* 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 2.1 Sept. 3, 2013

Annual Report 2 of 3

Address Job #

City

ANNUAL INSPECTION, TESTING, AND MAINTENANCE

Include ALL Quarterly Inspections

Reference Date Comments Only P,F,N/A

1.19 I Sprinklers 5.2.1

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

1.21 I Pipe and Fittings 5.2.2

1.22 I Hangers 5.2.3

1.23 I Seismic Braces 5.2.3

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 Control Valve - Position 13.3.3.2

2.6 T Control Valve – Operation 13.3.3.1

2.7 T Supervisory Devices 13.3.3.5

2.8 T Backflow Preventer Assemblies 13.6.2

2.9 T Small Hose Connections*

w/PRV Hose Valves – Partial Flow Test

13.5.2.3 13.5.3.3

2.10 T PRV – Fire Sprinkler Systems 13.5.1.3

3.1 M Control Valves 13.3.4

3.2 M Small Hose Connections* 13.5.6.3

3.3 M

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

14.3 Yes No

3.4 M System Returned to Service 4.5.3

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

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

Annual Report 3 of 3

Item Date Riser D C Deficiencies and Comments (cont.)

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

See Correction Form AES 10 for corrected deficiencies.

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.

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

Quarter 1st - Annual 2nd - Annual 3rd - Annual 4th - Annual

Date

Print Name

Signature

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSSELL LABARRE

CSLB:

Misc:

Riser NoRow1: 1

LocationRow1: @ 1A-125

Riser DiameterRow1: 3

Main Drain DiameterRow1: 2

Initial Static PressureRow1: 107

Residual PressureRow1: 75

Final Static PressureRow1: 105

PFNARow1: P

Riser NoRow2: 2

LocationRow2: @ 1A-125

Riser DiameterRow2: 2 1/2

Main Drain DiameterRow2: 1 1/4

Initial Static PressureRow2: 108

Residual PressureRow2: 75

Final Static PressureRow2: 105

PFNARow2: P

Riser NoRow3:

LocationRow3:

Riser DiameterRow3:

Main Drain DiameterRow3:

Initial Static PressureRow3:

Residual PressureRow3:

Final Static PressureRow3:

PFNARow3:

Riser NoRow4:

LocationRow4:

Riser DiameterRow4:

Main Drain DiameterRow4:

Initial Static PressureRow4:

Residual PressureRow4:

Final Static PressureRow4:

PFNARow4:

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: P

Date1331_2: P

Date1331_3: P

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: P psi526_2: P psi526_3: P psi526_4:

psi528: N/A psi528_2: N/A psi528_3: N/A psi528_4:

psi527: N/A psi527_2: N/A psi527_3: N/A psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: N/A psi1341_2: N/A psi1341_3: N/A psi1341_4:

psi13511: N/A psi13511_2: N/A psi13511_3: N/A psi13511_4:

psi1361: P psi1361_2: P psi1361_3: P psi1361_4:

psi516 1352 13551: N/A psi516 1352 13551_2: N/A psi516 1352 13551_3: N/A psi516 1352 13551_4:

psi13511_5: N/A psi13511_6: N/A psi13511_7: N/A psi13511_8:

Date521: 8/14/17

Comments Only521:

PFNA521: F

Date4111: 8/14/17

PFNAOwners Responsibility: P

Date522: 8/14/17

Owners Responsibility522:

PFNA522: P

Date523: 8/14/17

Owners Responsibility523:

PFNA523: P

Date523_2: 8/14/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 8/14/17

PFNAIf REQUIRED Enter F until results are returned from Lab: P

DateTitle 19 9041c: 8/14/17

PFNATitle 19 9041c: P

533 1326: 8/14/17 sec: P

1325 13334: 8/14/17

13332: 8/14/17

13331: 8/14/17

13335: 8/14/17

1362: 8/14/17

13523 13533: 8/14/17

13513: 8/14/17

1334: 8/14/17

13563: 8/14/17

143: 8/14/17

Yes No: P

453: 8/14/17

Yes No_2: P

ItemRow1:

DateRow1: 8/14/17

RiserRow1:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: PIV DISABLED DUE TO CONSTRUCTION

ItemRow2: 1.9

DateRow2: 8/14/17

RiserRow2: 1

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2: MISSING WHITE ESC. OUTSIDE 2A-230

ItemRow3: 1.9

DateRow3: 8/14/17

RiserRow3:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3: TRIM RING TYCO STYLE WHITE MISSIG REMOVE SPRINKLER HEAD TO REPLACE

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4:

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5:

ItemRow1_2:

DateRow1_2:

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1:

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2:

Date: 8-14-17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 8-14-17

Date2ndQtr: 11-13-17

Date3rdQtr: 2/15

Date4thQtr:

RiserCheckBox: Off

Number2:

9FormsAttached:

1:

61stQtr:

62ndQtr:

63rdQtr:

64thQtr:

621stQtr: 110

622ndQtr: 100

623rdQtr: 105

624thQtr:

SFMCheckBox: Off

CSLBCheckBox: Yes

Building Name: BUILDING 105

AddressRow1: 3801 MIRANDA AVE

City: PALO ALTO

Name: SIEMENS INDUSTRY, INC

Job: Q3

Text1: 60

Text2:

Text3: P

Text4:

Text5: P

Text6:

Text7: P

Text8:

Text9: P

Text10:

Text11: P

Text12:

Text13: N/A

Text14:

Text15: N/A

Text16:

Text17: P

Text18:

Text19: N/A

If REQUIRED Enter F until results are returned from LabTitle 19 9041c:

Group3:

3: Choice2

4: Choice1

Text21:

Text22:

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Text26:

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Text139:

CheckboxDeficiencies: Off

CheckboxAES10: Off

DeficiencyNumberAttached:

Text144: 11-13/17

Text145: JOSEPH CLOUD

Text146:

Text147: 2/15

Text148: MARCO GOITIA

Text149:

Text150:

Text151:

Text152:

CB1stAnnual: Yes

CB2ndAnnual: Off

CB3rdAnnual: Off

CB4thAnnual: Off

AES10Number Attached:

PropertyAddress2: 3801 MIRANDA AVE

ContractCity: HAYWARD

ContractState: CA

ContractZIP: 94545

DefDC: Choice2

DefDC2: Choice1

DefDC3: Choice1

DefDC4: Choice2

DefDC5: Off

DefDC6: Off

DefDC7: Off

DefDC8: Off

DefDC9: Off

DefDC10: Off

DefDC11: Off

DefDC12: Off

DefDC13: Off

DefDC14: Off

DefDC15: Off

DefDC16: Off

DefDC17: Off

DefDC18: Off

DefDC19: Off

DefDC20: Off

DefDC21: Off

DefDC22: Off

DefDC23: Off

DefDC24: Off

DefDC25: Off

DefDC26: Off

DefDC27: Off

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

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

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

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

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSSELL LABARRE

CSLB:

Misc:

Riser NoRow1: 1-4

LocationRow1: STAIR 1 FLOOR 4

Riser DiameterRow1: 4

Main Drain DiameterRow1: 2

Initial Static PressureRow1: 135

Residual PressureRow1: 90

Final Static PressureRow1: 135

PFNARow1: P

Riser NoRow2: 1-3

LocationRow2: STAIR 1 FLOOR 3

Riser DiameterRow2: 4

Main Drain DiameterRow2: 2

Initial Static PressureRow2: 145

Residual PressureRow2: 100

Final Static PressureRow2: 140

PFNARow2: P

Riser NoRow3: 1-2

LocationRow3: STAIR 1 FLOOR 2

Riser DiameterRow3: 4

Main Drain DiameterRow3: 2

Initial Static PressureRow3: 150

Residual PressureRow3: 100

Final Static PressureRow3: 145

PFNARow3: P

Riser NoRow4: 1-1

LocationRow4: STAIR 1 FLOOR 1

Riser DiameterRow4: 4

Main Drain DiameterRow4: 2

Initial Static PressureRow4: 150

Residual PressureRow4: 85

Final Static PressureRow4: 145

PFNARow4: P

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: P

Date1331_2: P

Date1331_3: P

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: P psi526_2: P psi526_3: P psi526_4:

psi528: P psi528_2: P psi528_3: P psi528_4:

psi527: P psi527_2: P psi527_3: P psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: NA psi1341_2: NA psi1341_3: N/A psi1341_4:

psi13511: P psi13511_2: P psi13511_3: P psi13511_4:

psi1361: P psi1361_2: P psi1361_3: P psi1361_4:

psi516 1352 13551: P psi516 1352 13551_2: P psi516 1352 13551_3: P psi516 1352 13551_4:

psi13511_5: P psi13511_6: P psi13511_7: P psi13511_8:

Date521: 8/15/17

Comments Only521:

PFNA521: F

Date4111: 8/15/17

PFNAOwners Responsibility: P

Date522: 8/15/17

Owners Responsibility522:

PFNA522: P

Date523: 8/15/17

Owners Responsibility523:

PFNA523: P

Date523_2: 8/15/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 8/15/17

PFNAIf REQUIRED Enter F until results are returned from Lab: N/A

DateTitle 19 9041c: 8/15/17

PFNATitle 19 9041c: P

533 1326: 8/15/17 sec: P

1325 13334: 8/15/17

13332: 8/15/17

13331: 8/15/17

13335: 8/15/17

1362: 8/15/17

13523 13533: 8/15/17

13513: 8/15/17

1334: 8/15/17

13563: 8/15/17

143: 8/15/17

Yes No: P

453: 8/15/17

Yes No_2: P

ItemRow1: 1.19

DateRow1: 8/15/17

RiserRow1:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: WRONG ESCH. WHITE VIKING HORIZON ESCH NEEDED @ C-445

ItemRow2:

DateRow2:

RiserRow2:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2: RECUT/ADJUST DROP & REPLACE MSG WHT VKG CONCEAL COVER PLATE @ A-354

ItemRow3:

DateRow3:

RiserRow3:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3: RECUT/ADJUST PENDANT @ PREVIOUS WHEELCHAIR REPAIR HALLWAY.

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4:

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5:

ItemRow1_2:

DateRow1_2:

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1:

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2:

Date: 8/15/17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 8/15/17

Date2ndQtr: 11/13/17

Date3rdQtr: 2/15

Date4thQtr:

RiserCheckBox: Yes

Number2:

9FormsAttached: 1

1:

61stQtr:

62ndQtr:

63rdQtr:

64thQtr:

621stQtr: 135

622ndQtr: 130

623rdQtr: 130

624thQtr:

SFMCheckBox: Off

CSLBCheckBox: Yes

Building Name: VA PALO ALTO BUILDING 5

AddressRow1: 3801 MIRANDA AVE

City: PALO ALTO, CA. 94304

Name: SIEMENS INDUSTRY, INC

Job: Q2

Text1: 45

Text2:

Text3: P

Text4:

Text5: P

Text6:

Text7: P

Text8:

Text9: P

Text10:

Text11: P

Text12:

Text13: P

Text14:

Text15: N/A

Text16:

Text17: P

Text18:

Text19: P

If REQUIRED Enter F until results are returned from LabTitle 19 9041c:

Group3:

3: Choice2

4: Choice1

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CheckboxDeficiencies: Off

CheckboxAES10: Off

DeficiencyNumberAttached:

Text144: 11/13/17

Text145: JOSEPH CLOUD

Text146:

Text147: 2/15/2018

Text148: MARCO GOITIA

Text149:

Text150:

Text151:

Text152:

CB1stAnnual: Yes

CB2ndAnnual: Off

CB3rdAnnual: Off

CB4thAnnual: Off

AES10Number Attached:

PropertyAddress2:

ContractCity: HAYWARD

ContractState: CA

ContractZIP: 94545

DefDC: Choice1

DefDC2: Choice1

DefDC3: Off

DefDC4: Off

DefDC5: Off

DefDC6: Off

DefDC7: Off

DefDC8: Off

DefDC9: Off

DefDC10: Off

DefDC11: Off

DefDC12: Off

DefDC13: Off

DefDC14: Off

DefDC15: Off

DefDC16: Off

DefDC17: Off

DefDC18: Off

DefDC19: Off

DefDC20: Off

DefDC21: Off

DefDC22: Off

DefDC23: Off

DefDC24: Off

DefDC25: Off

DefDC26: Off

DefDC27: Off

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

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

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

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

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSSELL LABARRE

CSLB:

Misc:

Riser NoRow1: 1

LocationRow1: MECHANICAL ROOM 117

Riser DiameterRow1: 3

Main Drain DiameterRow1: 1 1/4

Initial Static PressureRow1: 110

Residual PressureRow1: 55

Final Static PressureRow1: 100

PFNARow1: P

Riser NoRow2:

LocationRow2:

Riser DiameterRow2:

Main Drain DiameterRow2:

Initial Static PressureRow2:

Residual PressureRow2:

Final Static PressureRow2:

PFNARow2:

Riser NoRow3:

LocationRow3:

Riser DiameterRow3:

Main Drain DiameterRow3:

Initial Static PressureRow3:

Residual PressureRow3:

Final Static PressureRow3:

PFNARow3:

Riser NoRow4:

LocationRow4:

Riser DiameterRow4:

Main Drain DiameterRow4:

Initial Static PressureRow4:

Residual PressureRow4:

Final Static PressureRow4:

PFNARow4:

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: F

Date1331_2: F

Date1331_3: F

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: P psi526_2: P psi526_3: P psi526_4:

psi528: P psi528_2: P psi528_3: P psi528_4:

psi527: N/A psi527_2: N/A psi527_3: N/A psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: N/A psi1341_2: N/A psi1341_3: N/A psi1341_4:

psi13511: N/A psi13511_2: N/A psi13511_3: N/A psi13511_4:

psi1361: P psi1361_2: P psi1361_3: P psi1361_4:

psi516 1352 13551: N/A psi516 1352 13551_2: N/A psi516 1352 13551_3: N/A psi516 1352 13551_4:

psi13511_5: N/A psi13511_6: N/A psi13511_7: N/A psi13511_8:

Date521: 8/23/17

Comments Only521:

PFNA521: P

Date4111: 8/23/17

PFNAOwners Responsibility: P

Date522: 8/23/17

Owners Responsibility522:

PFNA522: P

Date523: 8/23/17

Owners Responsibility523:

PFNA523: P

Date523_2: 8/23/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 8/23/17

PFNAIf REQUIRED Enter F until results are returned from Lab: P

DateTitle 19 9041c: 8/23/17

PFNATitle 19 9041c: P

533 1326: 8/23/17 sec: P

1325 13334: 8/23/17

13332: 8/23/17

13331: 8/23/17

13335: 8/23/17

1362: 8/23/17

13523 13533: 8/23/17

13513: 8/23/17

1334: 8/23/17

13563: 8/23/17

143: 8/23/17

Yes No: P

453: 8/23/17

Yes No_2: P

ItemRow1: 1.1

DateRow1: 8/23/17

RiserRow1:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: INSPECTORS TEST VALVE ON ROOF @ MECHANICAL ROOM

ItemRow2:

DateRow2:

RiserRow2:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2: NO CHAINS, LOCKS, OR TAMPER SWITCH ON PIC OR BACKFLOW PREVENTER

ItemRow3:

DateRow3:

RiserRow3:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3: NO SIGN ON PIV, BACKFLOW PREVENTERS, OR FDC

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4:

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5:

ItemRow1_2:

DateRow1_2:

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1:

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2:

Date: 8-23-17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 8-23-17

Date2ndQtr: 11-13-17

Date3rdQtr: 2/15/18

Date4thQtr:

RiserCheckBox: Off

Number2:

9FormsAttached:

1:

61stQtr:

62ndQtr:

63rdQtr:

64thQtr:

621stQtr: 110

622ndQtr: 100

623rdQtr: 15

624thQtr:

SFMCheckBox: Off

CSLBCheckBox: Yes

Building Name: BULDING 530

AddressRow1: 3801 MIRANDA AVE

City: PALO ALTO

Name: SIEMENS INDUSTRY, INC

Job: Q3

Text1: 55

Text2:

Text3: P

Text4:

Text5: P

Text6:

Text7: P

Text8:

Text9: P

Text10:

Text11: P

Text12:

Text13: N/A

Text14:

Text15: N/A

Text16:

Text17: P

Text18:

Text19: N/A

If REQUIRED Enter F until results are returned from LabTitle 19 9041c:

Group3:

3: Choice2

4: Choice1

Text21:

Text22:

Text23:

Text26:

Text27:

Text28:

Text29:

Text32:

Text33:

Text34:

Text35:

Text38:

Text39:

Text40:

Text41:

Text44:

Text45:

Text46:

Text47:

Text50:

Text51:

Text52:

Text53:

Text56:

Text57:

Text58:

Text59:

Text62:

Text63:

Text64:

Text65:

Text68:

Text69:

Text70:

Text71:

Text74:

Text75:

Text76:

Text77:

Text80:

Text81:

Text82:

Text83:

Text86:

Text87:

Text88:

Text89:

Text92:

Text93:

Text94:

Text95:

Text98:

Text20:

Text99:

Text100:

Text103:

Text104:

Text105:

Text106:

Text109:

Text110:

Text111:

Text112:

Text115:

Text116:

Text117:

Text118:

Text121:

Text122:

Text123:

Text124:

Text127:

Text128:

Text129:

Text130:

Text133:

Text134:

Text135:

Text136:

Text139:

CheckboxDeficiencies: Off

CheckboxAES10: Off

DeficiencyNumberAttached:

Text144: 11-13-17

Text145: JOSEPH CLOUD

Text146:

Text147: 2/15

Text148: MARCO GOITIA

Text149:

Text150:

Text151:

Text152:

CB1stAnnual: Yes

CB2ndAnnual: Off

CB3rdAnnual: Off

CB4thAnnual: Off

AES10Number Attached:

PropertyAddress2: 3801 MIRANDA AVENUE

ContractCity: HAYWARD

ContractState: CA

ContractZIP: 94545

DefDC: Choice2

DefDC2: Choice1

DefDC3: Choice2

DefDC4: Choice2

DefDC5: Choice2

DefDC6: Off

DefDC7: Off

DefDC8: Off

DefDC9: Off

DefDC10: Off

DefDC11: Off

DefDC12: Off

DefDC13: Off

DefDC14: Off

DefDC15: Off

DefDC16: Off

DefDC17: Off

DefDC18: Off

DefDC19: Off

DefDC20: Off

DefDC21: Off

DefDC22: Off

DefDC23: Off

DefDC24: Off

DefDC25: Off

DefDC26: Off

DefDC27: Off

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

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

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

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

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSSELL LABARRE

CSLB:

Misc:

Riser NoRow1: 1

LocationRow1: FLOOR 2 STAIR 2

Riser DiameterRow1: 3

Main Drain DiameterRow1: 1 1/4

Initial Static PressureRow1: 87

Residual PressureRow1: 75

Final Static PressureRow1: 85

PFNARow1: P

Riser NoRow2: 2

LocationRow2: FLOOR 1 STAIR 2

Riser DiameterRow2: 3

Main Drain DiameterRow2: 1 1/4

Initial Static PressureRow2: 85

Residual PressureRow2: 78

Final Static PressureRow2: 85

PFNARow2: P

Riser NoRow3:

LocationRow3:

Riser DiameterRow3:

Main Drain DiameterRow3:

Initial Static PressureRow3:

Residual PressureRow3:

Final Static PressureRow3:

PFNARow3:

Riser NoRow4:

LocationRow4:

Riser DiameterRow4:

Main Drain DiameterRow4:

Initial Static PressureRow4:

Residual PressureRow4:

Final Static PressureRow4:

PFNARow4:

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: P

Date1331_2: P

Date1331_3: P

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: N/A psi526_2: N/A psi526_3: N/A psi526_4:

psi528: N/A psi528_2: N/A psi528_3: N/A psi528_4:

psi527: N/A psi527_2: N/A psi527_3: N/A psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: N/A psi1341_2: N/A psi1341_3: N/A psi1341_4:

psi13511: N/A psi13511_2: N/A psi13511_3: N/A psi13511_4:

psi1361: N/A psi1361_2: N/A psi1361_3: N/A psi1361_4:

psi516 1352 13551: N/A psi516 1352 13551_2: N/A psi516 1352 13551_3: N/A psi516 1352 13551_4:

psi13511_5: N/A psi13511_6: N/A psi13511_7: N/A psi13511_8:

Date521: 08/14/17

Comments Only521:

PFNA521: F

Date4111: 08/14/17

PFNAOwners Responsibility: P

Date522: 08/14/17

Owners Responsibility522:

PFNA522: P

Date523: 08/14/17

Owners Responsibility523:

PFNA523: P

Date523_2: 08/14/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 08/14/17

PFNAIf REQUIRED Enter F until results are returned from Lab: P

DateTitle 19 9041c: 08/14/17

PFNATitle 19 9041c: P

533 1326: 08/14/17 sec: P

1325 13334: 08/14/17

13332: 08/14/17

13331: 08/14/17

13335: 08/14/17

1362: 08/14/17

13523 13533: 08/14/17

13513: 08/14/17

1334: 08/14/17

13563: 08/14/17

143: 08/14/17

Yes No: P

453: 08/14/17

Yes No_2: P

ItemRow1:

DateRow1: 8-25-16

RiserRow1:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: ORANGE PROTECTIVE COVER IS STILL ON PENDANT IN B-111

ItemRow2:

DateRow2:

RiserRow2:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2: MISSING 2 WHITE 403 SKIRTS IN B-106

ItemRow3:

DateRow3:

RiserRow3:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3: REPLACE LOADED PENDANT OUTSIDE B-105

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4: MISSING WHITE 403 SKIRT IN B-115

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5: MISSING WHITE 403 SKIRT IN B-221

ItemRow1_2:

DateRow1_2: 8-15-17

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1: ITV IN SMALL ACCESS PANEL @ B-214

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2: MISSING LABEL FOR INSPECTORS TEST ACCESS PANEL

Date: 8-15-17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 8/15/17

Date2ndQtr: 11-13-17

Date3rdQtr: 2/15

Date4thQtr:

RiserCheckBox: Off

Number2:

9FormsAttached:

1:

61stQtr:

62ndQtr:

63rdQtr:

64thQtr:

621stQtr: 87

622ndQtr: 90

623rdQtr: 90

624thQtr:

SFMCheckBox: Off

CSLBCheckBox: Yes

Building Name: BUILDING 54

AddressRow1: 3801 MIRANDA AVE

City: PALO ALTO

Name: SIEMENS INDUSTRY, INC

Job: Q2

Text1: 55

Text2:

Text3: P

Text4:

Text5: P

Text6:

Text7: P

Text8:

Text9: P

Text10:

Text11: N/A

Text12:

Text13: N/A

Text14:

Text15: N/A

Text16:

Text17: P

Text18:

Text19: N/A

If REQUIRED Enter F until results are returned from LabTitle 19 9041c:

Group3:

3: Choice2

4: Choice1

Text21:

Text22:

Text23:

Text26: BUILD UP ON PENDANT @ B-221

Text27:

Text28:

Text29:

Text32: ITV IN SMALL ACCESS PANEL @ B-107

Text33:

Text34:

Text35:

Text38: PIV MISSING LOCK

Text39:

Text40:

Text41:

Text44: PIV STICKS & PROBLEMS GETTING OUT OF TROUBLE. RECOMMEND TO INVESTIGATE

Text45:

Text46:

Text47:

Text50:

Text51:

Text52:

Text53:

Text56:

Text57:

Text58:

Text59:

Text62:

Text63:

Text64:

Text65:

Text68:

Text69:

Text70:

Text71:

Text74:

Text75:

Text76:

Text77:

Text80:

Text81:

Text82:

Text83:

Text86:

Text87:

Text88:

Text89:

Text92:

Text93:

Text94:

Text95:

Text98:

Text20:

Text99:

Text100:

Text103:

Text104:

Text105:

Text106:

Text109:

Text110:

Text111:

Text112:

Text115:

Text116:

Text117:

Text118:

Text121:

Text122:

Text123:

Text124:

Text127:

Text128:

Text129:

Text130:

Text133:

Text134:

Text135:

Text136:

Text139:

CheckboxDeficiencies: Off

CheckboxAES10: Off

DeficiencyNumberAttached:

Text144: 11-13-17

Text145: JOSEPH CLOUD

Text146:

Text147: 2/15

Text148: MARCO GOITIA

Text149:

Text150:

Text151:

Text152:

CB1stAnnual: Yes

CB2ndAnnual: Off

CB3rdAnnual: Off

CB4thAnnual: Off

AES10Number Attached:

PropertyAddress2: 3801 MIRANDA AVENUE

ContractCity: HAYWARD

ContractState: CA

ContractZIP: 94545

DefDC: Choice1

DefDC2: Choice1

DefDC3: Choice1

DefDC4: Choice1

DefDC5: Choice1

DefDC6: Choice2

DefDC7: Choice2

DefDC8: Choice1

DefDC9: Choice2

DefDC10: Choice2

DefDC11: Choice2

DefDC12: Off

DefDC13: Off

DefDC14: Off

DefDC15: Off

DefDC16: Off

DefDC17: Off

DefDC18: Off

DefDC19: Off

DefDC20: Off

DefDC21: Off

DefDC22: Off

DefDC23: Off

DefDC24: Off

DefDC25: Off

DefDC26: Off

DefDC27: Off

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

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

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

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

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSS LABARRE 650-444-8239

CSLB:

Misc:

Riser NoRow1: 1

LocationRow1: OUTSIDE BUILDING

Riser DiameterRow1: 4"

Main Drain DiameterRow1: 2"

Initial Static PressureRow1: 89

Residual PressureRow1: 55

Final Static PressureRow1: 85

PFNARow1: P

Riser NoRow2:

LocationRow2:

Riser DiameterRow2:

Main Drain DiameterRow2:

Initial Static PressureRow2:

Residual PressureRow2:

Final Static PressureRow2:

PFNARow2:

Riser NoRow3:

LocationRow3:

Riser DiameterRow3:

Main Drain DiameterRow3:

Initial Static PressureRow3:

Residual PressureRow3:

Final Static PressureRow3:

PFNARow3:

Riser NoRow4:

LocationRow4:

Riser DiameterRow4:

Main Drain DiameterRow4:

Initial Static PressureRow4:

Residual PressureRow4:

Final Static PressureRow4:

PFNARow4:

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: P

Date1331_2: P

Date1331_3: P

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: N/A psi526_2: N/A psi526_3: N/A psi526_4:

psi528: N/A psi528_2: N/A psi528_3: N/A psi528_4:

psi527: N/A psi527_2: N/A psi527_3: N/A psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: N/A psi1341_2: N/A psi1341_3: N/A psi1341_4:

psi13511: N/A psi13511_2: N/A psi13511_3: N/A psi13511_4:

psi1361: N/A psi1361_2: N/A psi1361_3: N/A psi1361_4:

psi516 1352 13551: N/A psi516 1352 13551_2: N/A psi516 1352 13551_3: N/A psi516 1352 13551_4:

psi13511_5: N/A psi13511_6: N/A psi13511_7: N/A psi13511_8:

Date521: 8/14/17

Comments Only521:

PFNA521: P

Date4111: 8/14/17

PFNAOwners Responsibility: P

Date522: 8/14/17

Owners Responsibility522:

PFNA522: P

Date523: 8/14/17

Owners Responsibility523:

PFNA523: P

Date523_2: 8/14/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 8/14/17

PFNAIf REQUIRED Enter F until results are returned from Lab: N/A

DateTitle 19 9041c: 8/14/17

PFNATitle 19 9041c: P

533 1326: 8/14/17 sec: P

1325 13334: 8/14/17

13332: 8/14/17

13331: 8/14/17

13335: 8/14/17

1362: 8/14/17

13523 13533: 8/14/17

13513: 8/14/17

1334: 8/14/17

13563: 8/14/17

143: 8/14/17

Yes No: P

453: 8/14/17

Yes No_2: P

ItemRow1: 1.19

DateRow1: 8/14/17

RiserRow1: 1

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: RM 249 2 HEADS LESS THAN 6FT APART (PLUG 1)

ItemRow2:

DateRow2:

RiserRow2:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2:

ItemRow3:

DateRow3:

RiserRow3:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3:

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4:

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5:

ItemRow1_2:

DateRow1_2:

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1:

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2:

Date: 8/14/17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 8/14/17

Date2ndQtr: 11-13-17

Date3rdQtr: 2/15

Date4thQtr:

RiserCheckBox: Off

Number2:

9FormsAttached:

1:

61stQtr: 77

62ndQtr: 75

63rdQtr: 75

64thQtr:

621stQtr: 89

622ndQtr: 88

623rdQtr: 90

624thQtr:

SFMCheckBox: Off

CSLBCheckBox: Yes

Building Name: VA PALO ALTO BLDG MB-2

AddressRow1: 3801 MIRANDA AVE

City: PALO ALTO CA 94304

Name: SIEMENS INDUSTRY, INC

Job: Q3

Text1: 75

Text2:

Text3: P

Text4:

Text5: P

Text6:

Text7: P

Text8:

Text9: P

Text10:

Text11: P

Text12:

Text13: P

Text14:

Text15: P

Text16:

Text17: P

Text18:

Text19: P

If REQUIRED Enter F until results are returned from LabTitle 19 9041c:

Group3:

3: Choice2

4: Choice1

Text21:

Text22:

Text23:

Text26:

Text27:

Text28:

Text29:

Text32:

Text33:

Text34:

Text35:

Text38:

Text39:

Text40:

Text41:

Text44:

Text45:

Text46:

Text47:

Text50:

Text51:

Text52:

Text53:

Text56:

Text57:

Text58:

Text59:

Text62:

Text63:

Text64:

Text65:

Text68:

Text69:

Text70:

Text71:

Text74:

Text75:

Text76:

Text77:

Text80:

Text81:

Text82:

Text83:

Text86:

Text87:

Text88:

Text89:

Text92:

Text93:

Text94:

Text95:

Text98:

Text20:

Text99:

Text100:

Text103:

Text104:

Text105:

Text106:

Text109:

Text110:

Text111:

Text112:

Text115:

Text116:

Text117:

Text118:

Text121:

Text122:

Text123:

Text124:

Text127:

Text128:

Text129:

Text130:

Text133:

Text134:

Text135:

Text136:

Text139:

CheckboxDeficiencies: Off

CheckboxAES10: Off

DeficiencyNumberAttached:

Text144: 11-13-17

Text145: JOSEPH CLOUD

Text146:

Text147: 2/15

Text148: MARCO GOITIA

Text149:

Text150:

Text151:

Text152:

CB1stAnnual: Yes

CB2ndAnnual: Off

CB3rdAnnual: Off

CB4thAnnual: Off

AES10Number Attached:

PropertyAddress2: 3801 MIRANDA AVE

ContractCity: HAYWARD

ContractState: CA

ContractZIP: 94545

DefDC: Choice1

DefDC2: Choice1

DefDC3: Off

DefDC4: Off

DefDC5: Off

DefDC6: Off

DefDC7: Off

DefDC8: Off

DefDC9: Off

DefDC10: Off

DefDC11: Off

DefDC12: Off

DefDC13: Off

DefDC14: Off

DefDC15: Off

DefDC16: Off

DefDC17: Off

DefDC18: Off

DefDC19: Off

DefDC20: Off

DefDC21: Off

DefDC22: Off

DefDC23: Off

DefDC24: Off

DefDC25: Off

DefDC26: Off

DefDC27: Off

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

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

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

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

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSSELL LABARRE

CSLB:

Misc:

Riser NoRow1: 1

LocationRow1: OUTSIDE BUILDING

Riser DiameterRow1: 4"

Main Drain DiameterRow1: 2"

Initial Static PressureRow1: 86

Residual PressureRow1: 45

Final Static PressureRow1: 94

PFNARow1: P

Riser NoRow2:

LocationRow2:

Riser DiameterRow2:

Main Drain DiameterRow2:

Initial Static PressureRow2:

Residual PressureRow2:

Final Static PressureRow2:

PFNARow2:

Riser NoRow3:

LocationRow3:

Riser DiameterRow3:

Main Drain DiameterRow3:

Initial Static PressureRow3:

Residual PressureRow3:

Final Static PressureRow3:

PFNARow3:

Riser NoRow4:

LocationRow4:

Riser DiameterRow4:

Main Drain DiameterRow4:

Initial Static PressureRow4:

Residual PressureRow4:

Final Static PressureRow4:

PFNARow4:

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: P

Date1331_2: P

Date1331_3: P

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: N/A psi526_2: N/A psi526_3: N/A psi526_4:

psi528: N/A psi528_2: N/A psi528_3: N/A psi528_4:

psi527: N/A psi527_2: N/A psi527_3: N/A psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: N/A psi1341_2: N/A psi1341_3: N/A psi1341_4:

psi13511: N/A psi13511_2: N/A psi13511_3: N/A psi13511_4:

psi1361: N/A psi1361_2: N/A psi1361_3: N/A psi1361_4:

psi516 1352 13551: N/A psi516 1352 13551_2: N/A psi516 1352 13551_3: N/A psi516 1352 13551_4:

psi13511_5: N/A psi13511_6: N/A psi13511_7: N/A psi13511_8:

Date521: 8/14/17

Comments Only521:

PFNA521: F

Date4111: 8/14/17

PFNAOwners Responsibility: P

Date522: 8/14/17

Owners Responsibility522:

PFNA522: P

Date523: 8/14/17

Owners Responsibility523:

PFNA523: P

Date523_2: 8/14/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 8/14/17

PFNAIf REQUIRED Enter F until results are returned from Lab: N/A

DateTitle 19 9041c: 8/14/17

PFNATitle 19 9041c: P

533 1326: 8/14/17 sec: P

1325 13334: 8/14/17

13332: 8/14/17

13331: 8/14/17

13335: 8/14/17

1362: 8/14/17

13523 13533: 8/14/17

13513: 8/14/17

1334: 8/14/17

13563: 8/14/17

143: 8/14/17

Yes No: P

453: 8/14/17

Yes No_2: P

ItemRow1: 1.19

DateRow1: 8/14/17

RiserRow1: 1

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: REPLACE ONE MISSING CHROME 401 OUTER SKIRT IN RESTROOM BY 376

ItemRow2: 1.19

DateRow2: 8/14/17

RiserRow2: 1

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2: REPLACE 3 PAINTED CHROME RELIABLE 155* SRBG PENDANT @ (2) 382; (1) 384

ItemRow3: 1.19

DateRow3: 8/14/17

RiserRow3: 1

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3: ADJUST 401 OUTER SKIRT @ 354

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4:

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5:

ItemRow1_2:

DateRow1_2:

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1:

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2:

Date: 8/14/17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 08/14/17

Date2ndQtr: 11-13-17

Date3rdQtr: 2/15

Date4thQtr:

RiserCheckBox: Off

Number2:

9FormsAttached:

1:

61stQtr: 87

62ndQtr: 86

63rdQtr: 85

64thQtr:

621stQtr: 86

622ndQtr: 90

623rdQtr: 90

624thQtr:

SFMCheckBox: Off

CSLBCheckBox: Yes

Building Name: VA PALO ALTO BLDG MB-3

AddressRow1: 3801 MIRANDA AVE

City: PALO ALTO CA 94304

Name: SIEMENS INDUSTRY, INC

Job: Q3

Text1: 60

Text2:

Text3: P

Text4:

Text5: P

Text6:

Text7: P

Text8:

Text9: P

Text10:

Text11: N/A

Text12:

Text13: N/A

Text14:

Text15: N/A

Text16:

Text17: P

Text18:

Text19: N/A

If REQUIRED Enter F until results are returned from LabTitle 19 9041c:

Group3:

3: Choice2

4: Choice1

Text21:

Text22:

Text23:

Text26:

Text27:

Text28:

Text29:

Text32:

Text33:

Text34:

Text35:

Text38:

Text39:

Text40:

Text41:

Text44:

Text45:

Text46:

Text47:

Text50:

Text51:

Text52:

Text53:

Text56:

Text57:

Text58:

Text59:

Text62:

Text63:

Text64:

Text65:

Text68:

Text69:

Text70:

Text71:

Text74:

Text75:

Text76:

Text77:

Text80:

Text81:

Text82:

Text83:

Text86:

Text87:

Text88:

Text89:

Text92:

Text93:

Text94:

Text95:

Text98:

Text20:

Text99:

Text100:

Text103:

Text104:

Text105:

Text106:

Text109:

Text110:

Text111:

Text112:

Text115:

Text116:

Text117:

Text118:

Text121:

Text122:

Text123:

Text124:

Text127:

Text128:

Text129:

Text130:

Text133:

Text134:

Text135:

Text136:

Text139:

CheckboxDeficiencies: Off

CheckboxAES10: Off

DeficiencyNumberAttached:

Text144: 11-13-17

Text145: JOSEPH CLOUD

Text146:

Text147:

Text148:

Text149:

Text150:

Text151:

Text152:

CB1stAnnual: Yes

CB2ndAnnual: Off

CB3rdAnnual: Off

CB4thAnnual: Off

AES10Number Attached:

PropertyAddress2: 3801 MIRANDA AVE

ContractCity: HAYWARD

ContractState: CA

ContractZIP: 94545

DefDC: Choice1

DefDC2: Choice1

DefDC3: Choice1

DefDC4: Off

DefDC5: Off

DefDC6: Off

DefDC7: Off

DefDC8: Off

DefDC9: Off

DefDC10: Off

DefDC11: Off

DefDC12: Off

DefDC13: Off

DefDC14: Off

DefDC15: Off

DefDC16: Off

DefDC17: Off

DefDC18: Off

DefDC19: Off

DefDC20: Off

DefDC21: Off

DefDC22: Off

DefDC23: Off

DefDC24: Off

DefDC25: Off

DefDC26: Off

DefDC27: Off

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

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

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

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

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSSELL LABARRE

CSLB:

Misc:

Riser NoRow1: 1

LocationRow1: NE CORNER OF BUILDING

Riser DiameterRow1: 6

Main Drain DiameterRow1: 2

Initial Static PressureRow1: 90

Residual PressureRow1: 80

Final Static PressureRow1: 90

PFNARow1: P

Riser NoRow2:

LocationRow2:

Riser DiameterRow2:

Main Drain DiameterRow2:

Initial Static PressureRow2:

Residual PressureRow2:

Final Static PressureRow2:

PFNARow2:

Riser NoRow3:

LocationRow3:

Riser DiameterRow3:

Main Drain DiameterRow3:

Initial Static PressureRow3:

Residual PressureRow3:

Final Static PressureRow3:

PFNARow3:

Riser NoRow4:

LocationRow4:

Riser DiameterRow4:

Main Drain DiameterRow4:

Initial Static PressureRow4:

Residual PressureRow4:

Final Static PressureRow4:

PFNARow4:

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: P

Date1331_2: P

Date1331_3: P

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: NA psi526_2: NA psi526_3: NA psi526_4:

psi528: NA psi528_2: NA psi528_3: NA psi528_4:

psi527: NA psi527_2: NA psi527_3: NA psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: NA psi1341_2: NA psi1341_3: NA psi1341_4:

psi13511: NA psi13511_2: NA psi13511_3: NA psi13511_4:

psi1361: NA psi1361_2: NA psi1361_3: NA psi1361_4:

psi516 1352 13551: NA psi516 1352 13551_2: NA psi516 1352 13551_3: NA psi516 1352 13551_4:

psi13511_5: NA psi13511_6: NA psi13511_7: NA psi13511_8:

Date521: 8/17/17

Comments Only521:

PFNA521: P

Date4111: 8/17/17

PFNAOwners Responsibility: P

Date522: 8/17/17

Owners Responsibility522:

PFNA522: P

Date523: 8/17/17

Owners Responsibility523:

PFNA523: P

Date523_2: 8/17/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 8/17/17

PFNAIf REQUIRED Enter F until results are returned from Lab: P

DateTitle 19 9041c: 8/17/17

PFNATitle 19 9041c: P

533 1326: 8/17/17 sec: P

1325 13334: 8/17/17

13332: 8/17/17

13331: 8/17/17

13335: 8/17/17

1362: 8/17/17

13523 13533: 8/17/17

13513: 8/17/17

1334: 8/17/17

13563: 8/17/17

143: 8/17/17

Yes No: P

453: 8/17/17

Yes No_2: P

ItemRow1: 1.19

DateRow1: 8/17/17

RiserRow1: ALL

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: LAST 2 SSU 1/2" 165 ONLINE ON SW END OF BUILDING ARE PLUGGED, INSTALL

ItemRow2:

DateRow2:

RiserRow2:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2:

ItemRow3:

DateRow3:

RiserRow3:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3:

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4:

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5:

ItemRow1_2:

DateRow1_2:

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1:

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2:

Date: 8/17/17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 8/17/17

Date2ndQtr: 11/15//2017

Date3rdQtr: 2/15

Date4thQtr:

RiserCheckBox: Off

Number2:

9FormsAttached:

1:

61stQtr: 90

62ndQtr: 90

63rdQtr: 90

64thQtr:

621stQtr: 95

622ndQtr: 90

623rdQtr: 92

624thQtr:

SFMCheckBox: Off

CSLBCheckBox: Yes

Building Name: BUILDING 221

AddressRow1: 795 WILLOW ROAD

City: MENLO PARK

Name: SIEMENS INDUSTRY, INC

Job:

Text1: 35

Text2:

Text3: P

Text4:

Text5: P

Text6:

Text7: P

Text8:

Text9: P

Text10:

Text11: NA

Text12:

Text13: NA

Text14:

Text15: NA

Text16:

Text17: P

Text18:

Text19: NA

If REQUIRED Enter F until results are returned from LabTitle 19 9041c:

Group3:

3: Choice2

4: Choice1

Text21:

Text22:

Text23:

Text26:

Text27:

Text28:

Text29:

Text32:

Text33:

Text34:

Text35:

Text38:

Text39:

Text40:

Text41:

Text44:

Text45:

Text46:

Text47:

Text50:

Text51:

Text52:

Text53:

Text56:

Text57:

Text58:

Text59:

Text62:

Text63:

Text64:

Text65:

Text68:

Text69:

Text70:

Text71:

Text74:

Text75:

Text76:

Text77:

Text80:

Text81:

Text82:

Text83:

Text86:

Text87:

Text88:

Text89:

Text92:

Text93:

Text94:

Text95:

Text98:

Text20:

Text99:

Text100:

Text103:

Text104:

Text105:

Text106:

Text109:

Text110:

Text111:

Text112:

Text115:

Text116:

Text117:

Text118:

Text121:

Text122:

Text123:

Text124:

Text127:

Text128:

Text129:

Text130:

Text133:

Text134:

Text135:

Text136:

Text139:

CheckboxDeficiencies: Off

CheckboxAES10: Off

DeficiencyNumberAttached:

Text144: 11/15/17

Text145: JOSEPH CLOUD

Text146:

Text147: 2/15

Text148: MARCO GOITIA

Text149:

Text150:

Text151:

Text152:

CB1stAnnual: Yes

CB2ndAnnual: Off

CB3rdAnnual: Off

CB4thAnnual: Off

AES10Number Attached:

PropertyAddress2:

ContractCity: HAYWARD

ContractState: CA

ContractZIP: 94545

DefDC: Choice1

DefDC2: Choice2

DefDC3: Off

DefDC4: Choice2

DefDC5: Choice2

DefDC6: Off

DefDC7: Off

DefDC8: Off

DefDC9: Off

DefDC10: Off

DefDC11: Off

DefDC12: Off

DefDC13: Off

DefDC14: Off

DefDC15: Off

DefDC16: Off

DefDC17: Off

DefDC18: Off

DefDC19: Off

DefDC20: Off

DefDC21: Off

DefDC22: Off

DefDC23: Off

DefDC24: Off

DefDC25: Off

DefDC26: Off

DefDC27: Off

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

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

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

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

Address: 25821 INDUSTRIAL BLVD STE 300

License: 758796

Phone: 510-783-6000

SFM:

Contact PersonRow1: RUSSELL LABARRE

CSLB:

Misc:

Riser NoRow1: 1

LocationRow1: 1ST FL UTILITY CLOSET E131 A&D WINGS

Riser DiameterRow1: 4

Main Drain DiameterRow1: 2

Initial Static PressureRow1: 68

Residual PressureRow1: 40

Final Static PressureRow1: 52

PFNARow1: P

Riser NoRow2: 2

LocationRow2: 1ST FL UTILITY CLOSET E131 B,C,D,E WINGS

Riser DiameterRow2: 4

Main Drain DiameterRow2: 2

Initial Static PressureRow2: 68

Residual PressureRow2: 40

Final Static PressureRow2: 52

PFNARow2: P

Riser NoRow3:

LocationRow3:

Riser DiameterRow3:

Main Drain DiameterRow3:

Initial Static PressureRow3:

Residual PressureRow3:

Final Static PressureRow3:

PFNARow3:

Riser NoRow4:

LocationRow4:

Riser DiameterRow4:

Main Drain DiameterRow4:

Initial Static PressureRow4:

Residual PressureRow4:

Final Static PressureRow4:

PFNARow4:

Riser NoRow5:

LocationRow5:

Riser DiameterRow5:

Main Drain DiameterRow5:

Initial Static PressureRow5:

Residual PressureRow5:

Final Static PressureRow5:

PFNARow5:

Date1331: P

Date1331_2: P

Date1331_3: P

Date1331_4:

Date1332: P

Date1332_2: P

Date1332_3: P

Date1332_4:

Date525: P

Date525_2: P

Date525_3: P

Date525_4:

Date525_5: P

Date525_6: P

Date525_7: P

Date525_8:

Date5241: P

Date5241_2: P

Date5241_3: P

Date5241_4:

psi5241: P psi5241_2: P psi5241_3: P psi5241_4:

psi526: NA psi526_2: NA psi526_3: NA psi526_4:

psi528: NA psi528_2: NA psi528_3: NA psi528_4:

psi527: NA psi527_2: NA psi527_3: NA psi527_4:

psi5214: P psi5214_2: P psi5214_3: P psi5214_4:

psi137: P psi137_2: P psi137_3: P psi137_4:

psi1341: P psi1341_2: P psi1341_3: P psi1341_4:

psi13511: NA psi13511_2: NA psi13511_3: NA psi13511_4:

psi1361: NA psi1361_2: NA psi1361_3: NA psi1361_4:

psi516 1352 13551: NA psi516 1352 13551_2: NA psi516 1352 13551_3: NA psi516 1352 13551_4:

psi13511_5: NA psi13511_6: NA psi13511_7: NA psi13511_8:

Date521: 8/17/17

Comments Only521:

PFNA521: P

Date4111: 8/17/17

PFNAOwners Responsibility: NA

Date522: 8/17/17

Owners Responsibility522:

PFNA522: P

Date523: 8/17/17

Owners Responsibility523:

PFNA523: P

Date523_2: 8/17/17

Owners Responsibility523_2:

PFNA523_2: P

Date531: 8/17/17

PFNAIf REQUIRED Enter F until results are returned from Lab: P

DateTitle 19 9041c: 8/17/17

PFNATitle 19 9041c: P

533 1326: 8/17/17 sec: P

1325 13334: 8/17/17

13332: 8/17/17

13331: 8/17/17

13335: 8/17/17

1362: 8/17/17

13523 13533: 8/17/17

13513: 8/17/17

1334: 8/17/17

13563: 8/17/17

143: 8/17/17

Yes No: P

453: 8/17/17

Yes No_2: P

ItemRow1: 1.19

DateRow1: 8/17/17

RiserRow1: ALL

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: SPRINKLER UPRIGHT COVERED IN PAINTERS TAPE @ BOILER ROOM 110A

ItemRow2:

DateRow2:

RiserRow2:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2: MISSING 401 OUTER CHROME SKIRT AND 401 @ D-133

ItemRow3:

DateRow3:

RiserRow3:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3: MISSING 401 OUTER CHROME SKIRT @ A-159

ItemRow4:

DateRow4:

RiserRow4:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4: UPRIGHT PENDANT POS. CENTRAL 165 PENDANDT CHROME FUSIBLE LINK @ D-133

ItemRow5:

DateRow5:

RiserRow5:

Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5: MISSING 403 OUTER CHROME SKIRT @ D-130

ItemRow1_2: 1.119

DateRow1_2: 8/17/17

RiserRow1_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1: ADJUST 403 OUTER CHROME SKIRT @ B-113B

ItemRow2_2:

DateRow2_2:

RiserRow2_2:

Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2: MISSING 401 OUTER CHROME SKIRT @ C-139D

Date: 8/17/17

Print Name: SERGIO ORTIZ

Signature:

Date1stQtr: 8/17/117

Date2ndQtr: 11/15/2017

Date3rdQtr: 2/16

Date4thQtr:

RiserCheckBox: Off

Number2: