VANCH MATHER BUILDING 700 ANNUAL AND QSP.pdf

AES 1 Sept. 3, 2013

Inspection, Testing, and Maintenance Cover Sheet NFPA25 as amended by CCR, Title 19

Property Information:

Name: VANCH MATHER BUILDING 700 Occupancy/Use: LIGHT/ORD

Address: 10535 HOSPITAL WAY Construction Type: WOOD/CONCRETE

City: RANCHO CORDOVA, CA No. Stories: 6

ZIP: 95655 Year Constructed: N/A

Contact: DOUG GAMBRELL

Telephone: (440)319-2479

Contractor Information: Number of System Risers 6

Copy sent to:

Name:

Owner Date:

Address Fire AHJ Date:

City: Contractor Date:

State: NOTES:

1) For specific inspection, testing, and maintenance requirements and information, see NFPA 25, 2011 edition as amended by California Code of Regulations, Title 19, §901 to §906.

2) Inspection items may be performed by the owner in accordance with California Code of Regulations, Title 19, §904.1(a)

Telephone:

CA License#: 905493

Job #: HURTVET 3626120P1265

Performed by:

Check box for each system inspected and enter the number of forms used for inspection. Check boxes (Fail or Pass) to indicate status of inspected system at end of inspection.

Forms Included with this Report

NFPA 25

Chapter Number of Forms N/A Fail* Pass

Automatic Sprinkler System 5 1

Standpipe and Hose System 6

Private Water Supply System 7

Fire Pump 8

Water Storage Tank 9

Water Spray System 10

Foam Water Sprinkler System 11

Water Mist System 12

Concerns that are Not Deficiencies (i.e. Non-Sprinklered Areas) Yes No

*See "Deficiencies and Comments" section at end of each respective form.

Wet Pipe Fire Sprinkler System

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

Quarterly and Annual Report

Property Information

Contractor or Licensed Owner Information

Building VANCH MATHER BUILDING 700

Address 10535 HOSPITAL WAY

City RANCHO CORDOVA, CA License # 905493 Contact DOUG GAMBRELL SFM Job # HURTVET 3626120P1265

Phone (440)319-2479 CSLB Misc. ANNUAL Quarterly Sprinkler Inspection

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

1 1ST FLOOR (STAIRWELL 2) 2 ½ ’’ 1 ½ ‘’ 140 PSI N/A N/A P

2 2ND FLOOR(STAIRWELL 2) 2 ½ ’’ 1 ¼ ‘’ 131 PSI N/A N/A P

3 3RD FLOOR(STAIRWELL 2) 2 ½ ’’ 1 ¼ ‘’ 128 PSI N/A N/A P

4 4TH FLOOR(STAIRWELL 2) 2 ½ ’’ 1 ¼ ‘’ 121 PSI N/A N/A P

5 5TH FLOOR(STAIRWELL 2) 2 ½ ’’ 1 ¼ ‘’ 116 PSI N/A N/A P

6 6TH FLOOR (STAIRWELL 2) 2 ½ ’’ 1 ¼ ‘’ 108 PSI N/A N/A P

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 7-20-21 10-5-21 12-7-21

1.1 I Control Valves – Identification Sign 13.3.1 P P P

1.2 I Control Valves – Inspection 13.3.2 P P P

1.3 I Waterflow Alarm Devices 5.2.5 P P P

1.4 I Supervisory Devices 5.2.5 P P P

1.5 I Gauges (Wet Pipe Systems) 5.2.4.1 P P P

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 P P P

1.9 I Hydraulic Design Information Sign

(For Hydraulically Designed Systems) 5.2.6 P P P

1.10 I

General Information Sign (Not Required for System prior to 2007 Edition of NFPA 13)

5.2.8 P P P

1.11 I Heat Tape 5.2.7 NA N/A N/A

1.12 I Spare Sprinklers 5.2.1.4 P P P

1.13 I Fire Department Connections 13.7 P P P

1.14 I Alarm Valves – Exterior Inspection 13.4.1 P P P

1.15 I Pressure Reducing Valves 13.5.1.1 N N/A N/A

1.16 I Backflow Preventers 13.6.1 P P P

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

13.5.5.1 N/A N/A N/A

1.18 I PRV – Fire Sprinkler Systems 13.5.1.1 N/A N/A N/A

* 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.

Fire Sprinkler System

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

Quarterly and Annual Report

Name

Address 10535 HOSPITAL WAY Job # HURTVET 3626120P1265

City RANCHO CORDOVA, CA Misc. ANNUAL Quarterly Sprinkler Inspection

SEMI ANNUAL INSPECTION, TESTING, AND MAINTENANCE

Include ALL Quarterly Inspections

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

1.19 I Sprinklers 5.2.1 12-7-21 N

1.20 I Buildings (Freeze Protection) 4.1.1.1 12-7-21 Owner’s Responsibility N

1.21 I Pipe and Fittings 5.2.2 12-7-21 N

1.22 I Hangers 5.2.3 12-7-21 N

1.23 I Seismic Braces 5.2.3 12-7-21 N

2.1 T Field Service Test Required (Send

Report to Fire Code Official) 5.3.1 12-7-21 If REQUIRED, Enter 'F' until results are returned from Lab N

2.2 T Recalled Sprinklers

If not present = Pass; If present = Fail Title 19 904.1(c) 12-7-21 N

2.3 T Water Flow Alarm Devices 90

sec. maximum - (Enter Time )

5.3.3 13.2.6

12-7-21 90 sec. P

2.4 T Main Drain Test

(Enter Data on Page 1 of this Form)

13.2.5 13.3.3.4

12-7-21 P

2.5 T Control Valve - Position 13.3.3.2 12-7-21 P

2.6 T Control Valve – Operation 13.3.3.1 12-7-21 P

2.7 T Supervisory Devices 13.3.3.5 12-7-21 P

2.8 T Backflow Preventer Assemblies 13.6.2 12-7-21 P

2.9 T Small Hose Connections* w/PRV Hose

Valves – Partial Flow Test

13.5.2.3 13.5.3.3

12-7-21 N

2.10 T PRV – Fire Sprinkler Systems 13.5.1.3 12-7-21 N

3.1 M Control Valves 13.3.4 12-7-21 P

3.2 M Small Hose Connections* 13.5.6.3 12-7-21 N

3.3 M

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

14.3 12-7-21 Yes

No N

3.4 M System Returned to Service 4.5.3 12-7-21 Yes

No P

* 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.

VHAMACForemM Highlight

Fire Sprinkler System

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

Quarterly and Annual Report

Name

Address 10535 HOSPITAL WAY Job # HURTVET 3626120P1265

City RANCHO CORDOVA, CA Misc. ANNUAL Quarterly Sprinkler Inspection

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 QUARTERLY SPRINKLER INSPECTION*****

Notes:

END OF REPORT

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.

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

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

Date 7-20-21 10-5-21 12-7-21 Print Name TY KELL TY KELL TY KELL

Signature TY KELL TY KELL TY KELL