Building Reports Attachment 2.pdf
PDF 3 MB Posted
- Attached to
- H912--NFPA 5 Year Sprinkler Testing VAPAHCS
- Solicitation number
- 36C26126Q0335
About this file
Summary of Fire Sprinkler System Inspection and Testing Documentation
These documents are Form AES 2.2 inspection, testing, and maintenance reports for wet pipe fire sprinkler systems operating under California Code of Regulations Title 19 and NFPA 25 standards. The reports cover two properties: Building 90 located at 4951 Arroyo Rd., Livermore, CA 94550 (a 2-story concrete/wood construction with light/ordinary occupancy) and VA Livermore Building 62 at the same address (a 7-story Type I-A construction classified as institutional). Both inspections were performed annually as of July 30, 2025 for Building 90 and September 30, 2024 for Building 62.
Building 90 contains two system risers with main drain diameters of 2 inches each, achieving initial static pressures of 59-65 psi and final static pressures of 60-65 psi. The quarterly and annual inspections identified multiple deficiencies including out-of-date pressure gauges, painted sprinkler heads (155% QR chrome pendents) in various locations throughout the building, and one missing 401 2nd stage trim component. Building 62 contains four risers with main drain diameters ranging from 1-1/4 to 2 inches, with pressure readings of 57-65 psi initial and 50-65 psi residual. Deficiencies noted include gauges requiring replacement and missing outer trim components on multiple units. Both systems passed control valve operations, backflow preventer testing, and fire department connection inspections, with reports indicating the equipment is fully operable except for noted deficiencies requiring correction.
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Other files
| File | Type | Posted |
|---|---|---|
| Building Reports Attachment 3.pdf | ||
| Building Reports Attachment 1.pdf | ||
| Sprinkler Riser List Attachment 4.xlsx | XLSX spreadsheet | |
| 36C26126Q0335 0001.docx | DOCX document | |
| 36C26126Q0335.docx | DOCX document | |
| Attachment 3 WD 2015-5623.pdf | ||
| Attachment 1 WD 2015-5637.pdf | ||
| Attachment 2 WD 2015-5641.pdf |
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Text version
Form AES 2.2 Sept. 3, 2013
Inspection, Testing, and Maintenance Cover Sheet NFPA25 as amended by CCR, Title 19
Property Information:
Name:
Building 90
Occupancy/Use: Concrete/wood
Address:
4951 Arroyo Rd.
Construction Type: Light/ord.
City:
Livermore , CA.
No. Stories: 2
ZIP:
94550
Year Constructed: N/A
Contact:
Telephone:
Contractor Information: Number of System Risers 2
Copy sent to:
Name: Owner Date: 07-30-25
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#:
Job #:
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
Annual Report
Property Information Contractor or Licensed Owner Information
Building Building 90
Address 4951 Arroyo Rd.
Livermore , CA.
City 94550 License #
Contact SFM Job #
Phone 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
1 Room A-108 - 1st floor EHS closet near dock 4 2 59 65 60 P
2 Room C-111 - 1st floor closet inside office space 2 2 65 60 65 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
02-15-25 5-14-25 07-30-25
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 F F F
1.6 I Enter Water Supply Pressure Below Riser Check 5.2.4.1 65 65 psi 67 psi psi
1.7 I Enter Water Supply Pressure Above Riser Check 5.2.4.1 75 72 psi 72 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 N/A 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 N/A N/A N/A
1.15 I Pressure Reducing Valves 13.5.1.1 N/A 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
Fire Sprinkler System
California Code of Regulations - Title 19 Inspection, Testing, and Maintenance
Annual Report
Property Information Contractor or Licensed Owner Information
Building Building 90
Address 4951 Arroyo Rd.
Livermore , CA.
City 94550 License #
Contact SFM Job #
Phone CSLB Misc.
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.
Annual INSPECTION, TESTING, AND MAINTENANCE Includes ALL Quarterly and Annual Inspections, Tests, and Maintenance Items
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
1.1 I Control Valves – Identification Sign 13.3.1 07-30-25 P
1.2 I Control Valves – Inspection 13.3.2 07-30-25 P
1.3 I Waterflow Alarm Devices 5.2.5 07-30-25 P
1.4 I Supervisory Devices 5.2.5 07-30-25 P
1.5 I Gauges (Wet Pipe Systems) 5.2.4.1 07-30-25 P
1.6 I Hydraulic Design Information Sign (For
Hydraulically Designed Systems)
5.2.6 07-30-25 P
1.7 I Enter Water Supply Pressure Below Riser Check 5.2.4.1 07-30-25 P
1.8 I Enter Water Supply Pressure Above Riser Check 5.2.4.1 07-30-25 P
1.9 I Pressure Readings Acceptable 5.2.4.1 07-30-25 P
1.10 I General Information Sign
(Not Required for System Prior to 2007 Edition NFPA 13)
5.2.8 07-30-25 P
1.11 I Heat Tape 5.2.7 07-30-25 N/A
1.12 I Spare Sprinklers 5.2.1.4 07-30-25 P
1.13 I Fire Department Connections 13.7 07-30-25 P
1.14 I Alarm Valves – Exterior Inspection 13.4.1 07-30-25 N/A
1.15 I Pressure Reducing Valves 13.5.1.1 07-30-25 N/A
1.16 I Backflow Preventers 13.6.1 07-30-25 P
Fire Sprinkler System
California Code of Regulations - Title 19 Inspection, Testing, and Maintenance
Annual Report
Property Information Contractor or Licensed Owner Information
Building Building 90 Name
Address 4951 Arroyo Rd. Job #
City Livermore , CA. Misc.
ANNUAL INSPECTION, TESTING, AND MAINTENANCE
Include ALL Quarterly Inspections (See AES 2.1)
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 Small Hose Connections - Hose Valve* 5.1.6, 13.5.2
13.5.5.1
07-30-25 P
1.18 I PRV – Fire Sprinkler Systems 13.5.1.1 07-30-25 N/A
1.19 I Buildings (Freeze Protection) 4.1.1.1 07-30-25 Owner’s Responsibility N/A
1.20 I Sprinklers 5.2.1 07-30-25 F
1.21 I Sprinklers - Accessible Concealed Space 5.2.1.1.6 07-30-25 P
1.22 I Pipe and Fittings 5.2.2 07-30-25 P
1.23 I Pipe and Fittings - Accessible Concealed Space 5.2.2.3 07-30-25 P
1.24 I Hangers 5.2.3 07-30-25 P
1.25 I Hangers - Accessible Concealed Space 5.2.3.3 07-30-25 P
1.26 I Seismic Braces 5.2.3 07-30-25 P
1.27 I Seismic Braces - Accessible Concealed Space 5.2.3.3 07-30-25 P
1.28 I Unsprinklered Areas CFC 901.4 07-30-25 YES NO N/A
2.1 T Field Service Test Required Send
Report to Fire Code Official
5.3.1 07-30-25 If REQUIRED, Enter ‘F’ until results are returned from Lab N/A
2.2 T Recalled Sprinklers
If not present = Pass; If present = Fail
Title 19 904.1(c) 07-30-25 P
2.3 T Water Flow Alarm Devices 90
secs max. Enter time
5.3.3 13.2.6
07-30-25 90 sec. P
2.4 T Main Drain Test
(Enter data on Page 1 of this form)
13.2.5 13.3.3.4
07-30-25 P
2.5 T Control Valve - Position 13.3.3.2 07-30-25 P
2.6 T Control Valve – Operation 13.3.3.1 07-30-25 P
2.7 T Supervisory Devices 13.3.3.5 07-30-25 P
2.8 T Backflow Preventer Assemblies 13.6.2 07-30-25 P
2.9 T Small Hose Connections*
w/PRV Hose Valves – Partial Flow Test
13.5.2.3 13.5.3.3
07-30-25 N/A
2.10 T PRV – Fire Sprinkler Systems 13.5.1.3 07-30-25 N/A
2.11 T Pressure Gauges - Calibration 5.3.2 07-30-25 F
2.12 T
Small Hose Connections
* 13.5.6.2.2 07-30-25 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
Annual Report
Property Information Contractor or Licensed Owner Information
Building Building 90 Name
Address 4951 Arroyo Rd. Job #
City Livermore , CA. Misc.
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
3.1 M Check Valves - Internal inspection 13.4.2 07-30-25 P
3.2 M Control Valves 13.3.4 07-30-25 P
3.3 M FDC - Backflush
14.3.2.3 14.3.2.4
07-30-25 P
3.4 M Internal Pipe Inspection - See Deficiencies and
Comments Section for Results.
14.2 07-30-25 Yes No N/A
3.5 M
Obstruction Investigation Required. If "Yes", See Deficiencies and Comments Section for Results 14.3 07-30-25 P
3.6 M System Returned to Service 4.5.3 07-30-25 Yes
No P
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 FIRE SPRINKLER INSPECTION*****
1.5 7-30-25 1 X Two out of date gauges on riser
1.20 7-30-25 1 X Two painted 155% QR crome pendents ½ in dinning hall
1.20 7-30-25 1 X 4 painted 155% QR crome pendents ½ in hall next to room A-128
1.20 7-30-25 1 X 3 painted 155% QR crome pendents ½ in room A-102
1.20 7-30-25 1 X 2 painted 155% QR crome pendents ½ in hall next to room A-100
1.20 7-30-25 1 X 1 painted in entrance of building and one standard response mixed with QR head. Need to change standard response head to a 155% QR crome ½ pendent.
1.20 7-30-25 1 X 1 painted 155% QR crome pendents ½ outside entrance next to room c-105
1.20 7-30-25 1 X 1 painted 155% QR crome pendents ½ in room C-104
1.20 7-30-25 1 X 1 Missing 401 2nd stage trim in room B-233 white
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.
Print Name
Signature Date 07-30-25
Inspection, Testing, and Maintenance Cover Sheet NFPA25 as amended by CCR, Title 19
Property Information:
Name: Occupancy/Use:
Address: Construction Type:
City: No. Stories:
ZIP: Year Constructed:
Contact:
Telephone:
Contractor Information: Number of System Risers
Name: Copy sent to:
Address: Owner Date:
City: Fire AHJ Date:
State: Contractor Date:
Telephone:
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)
CA License#:
Job #:
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
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.
AES 1 September 3, 2013
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 License # PhoneContact Person
SFM Job # CSLB Misc.
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 (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
Email Address
City
Telephone
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
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
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
Yes No
* 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.
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
Form AES 2.1 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
D = Deficiency C = Comment (Indicate type )
Item Date Riser D C Deficiencies and Comments (cont.)
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.
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
Form AES 2.1 Sept. 3, 2013
| Livermore VA Building 90 Annual sprinkler Q3 inspection 7-30-25 Fail |
| VAL Bldg. 62 - 4951 Arroyo Rd. (Sprinkler) Annual Report - Sept, 2024 |
| PropertyZIP: 94550 |
| DDOccupancyUse: [I2] |
| DDConstructionType: [Type I-A] |
| NumberStories: 7 |
| YrConstructed: |
| CALicense: |
| Inspector: |
| DDOwner: On |
| OwnerDate: |
| 0: 9/30/24 |
| Fire AHJ: Off |
| AHJDate: |
| Contractor: Off |
| ContractorDate: |
| AutoSprinkler: On |
| 5: 1 |
| Sprinkler NA: |
| 0: Off |
| 1: Off |
| 2: Off |
| 3: Off |
| 4: Off |
| 5: Off |
| 6: Off |
| 7: Off |
| Sprinkler Fail: |
| 0: Off |
| 1: Off |
| 2: Off |
| 3: Off |
| 4: Off |
| 5: Off |
| 6: Off |
| 7: Off |
| Sprinkler Pass: |
| 0: Yes |
| 1: Off |
| 2: Off |
| 3: Off |
| 4: Off |
| 5: Off |
| 6: Off |
| 7: Off |
| Standpipe: Off |
| 6: 0 |
| PrivateWater: Off |
| 7: 0 |
| FirePump: Off |
| 8: 0 |
| WaterStorage: Off |
| 9: 0 |
| WaterSpray: Off |
| 10: 0 |
| Foam: Off |
| 11: 0 |
| WaterMist: Off |
| 12: 0 |
| Concerns: Off |
| Yes: Off |
| No: On |
| PropertyName: VA Livermore - Bldg 62 |
| Address 1: 4951 Arroyo Rd. |
| PropertyCity: Livermore |
| Contact: |
| ContactTelephone: |
| License: 758796 |
| SFMCheckBox: Off |
| SFM: |
| CSLBCheckBox: Yes |
| CSLB: |
| ContractorName: |
| ContractorAddress: |
| ContractorCity: |
| ContractorSTate: |
| ContractZIP: 94538 |
| ContractorTelephone: |
| JobNumber: |
| Misc: |
| Riser NoRow1: 1 |
| LocationRow1: Basement main supply |
| Riser DiameterRow1: 6" |
| Main Drain DiameterRow1: 2" |
| Initial Static PressureRow1: 65 |
| Residual PressureRow1: 60 |
| Final Static PressureRow1: 65 |
| PFNARow1: P |
| Riser NoRow2: 2 |
| LocationRow2: (East) Riser closet - 1st to 7th floor |
| Riser DiameterRow2: 3" |
| Main Drain DiameterRow2: 1-1/4" |
| Initial Static PressureRow2: 57 |
| Residual PressureRow2: 50 |
| Final Static PressureRow2: 57 |
| PFNARow2: P |
| Riser NoRow3: 3 |
| LocationRow3: (West) Riser closet - 1st to 7th floor |
| Riser DiameterRow3: 3" |
| Main Drain DiameterRow3: 1-1/4" |
| Initial Static PressureRow3: 60 |
| Residual PressureRow3: 40 |
| Final Static PressureRow3: 60 |
| PFNARow3: P |
| Riser NoRow4: 4 |
| LocationRow4: (Center) Riser closet - 1st to roof |
| Riser DiameterRow4: 4" |
| Main Drain DiameterRow4: 2" |
| Initial Static PressureRow4: 60 |
| Residual PressureRow4: 50 |
| Final Static PressureRow4: 60 |
| PFNARow4: P |
| Riser NoRow5: |
| LocationRow5: |
| Riser DiameterRow5: |
| Main Drain DiameterRow5: |
| Initial Static PressureRow5: |
| Residual PressureRow5: |
| Final Static PressureRow5: |
| PFNARow5: |
| RiserCheckBox: Off |
| Number2: |
| 9FormsAttached: |
| Date1331: |
| Date1332: |
| Date525: |
| Date525_5: |
| Date5241: |
| 1: |
| 61stQtr: |
| 621stQtr: |
| 62ndQtr: |
| 622ndQtr: |
| 63rdQtr: 64 |
| 623rdQtr: 64 |
| 64thQtr: 65 |
| 624thQtr: 65 |
| psi5241: |
| psi137: |
| psi1341: |
| psi13511: |
| psi1361: |
| psi516 1352 13551: |
| psi13511_5: |
| Date1331_2: |
| Date1332_2: |
| Date525_2: |
| Date525_6: |
| Date5241_2: |
| psi5241_2: |
| psi526_2: |
| psi528_2: |
| psi527_2: |
| psi5214_2: |
| psi137_2: |
| psi1341_2: |
| psi13511_2: |
| psi1361_2: |
| psi516 1352 13551_2: |
| psi13511_6: |
| Date1331_3: P |
| Date1332_3: P |
| Date525_3: P |
| Date525_7: P |
| Date5241_3: P |
| psi5241_3: P |
| psi526_3: N/A |
| psi528_3: N/A |
| psi527_3: N/A |
| psi5214_3: P |
| psi137_3: P |
| psi1341_3: P |
| psi13511_3: N/A |
| psi1361_3: P |
| psi516 1352 13551_3: N/A |
| psi13511_7: N/A |
| psi526: |
| psi528: |
| psi527: |
| psi5214: |
| Date1331_4: F |
| Date1332_4: P |
| Date525_4: P |
| Date525_8: P |
| Date5241_4: F |
| psi5241_4: P |
| psi526_4: N/A |
| psi528_4: N/A |
| psi527_4: N/A |
| psi5214_4: P |
| psi137_4: P |
| psi1341_4: P |
| psi13511_4: N/A |
| psi1361_4: P |
| psi516 1352 13551_4: N/A |
| psi13511_8: N/A |
| EmailAddress: |
| Date521: 9/30/24 |
| Comments Only521: |
| PFNA521: P |
| Date4111: |
| PFNAOwners Responsibility: N/A |
| Date522: |
| Owners Responsibility522: |
| PFNA522: P |
| Date523: |
| Owners Responsibility523: |
| PFNA523: P |
| Date523_2: |
| Owners Responsibility523_2: |
| PFNA523_2: P |
| Date531: |
| PFNAIf REQUIRED Enter F until results are returned from Lab: N/A |
| DateTitle 19 9041c: |
| If REQUIRED Enter F until results are returned from LabTitle 19 9041c: |
| PFNATitle 19 9041c: P |
| 533 1326: |
| Text1: 50 |
| sec: P |
| 1325 13334: |
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| Text3: P |
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| Text11: N/A |
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| Text17: P |
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| Text19: N/A |
| 143: |
| Group3: |
| 3: Choice2 |
| 4: Choice1 |
| Yes No: N/A |
| 453: |
| Yes No_2: P |
| ItemRow1: 1.5 |
| DateRow1: 9/30/24 |
| RiserRow1: All |
| DefDC: Choice1 |
| Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow1: (21) Gauges out of date Replace |
| ItemRow2: 1.19 |
| DateRow2: 9/30/24 |
| RiserRow2: 5 |
| DefDC2: Choice1 |
| Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow2: (1) Unit 537 Missing Outer off White 401 outer trim |
| ItemRow3: 1.19 |
| DateRow3: 9/30/24 |
| RiserRow3: 6 |
| DefDC3: Choice1 |
| Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow3: (1) Unit 632 Missing Central Chrome Semi Rec outer trim |
| ItemRow4: |
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| DefDC4: Off |
| Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow4: (1)8 unit 336 Missing Central Chrome 804a trim |
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| DefDC5: Off |
| Deficiencies and Comments Indicate all equipment devices and parts that were repaired or replacedRow5: |
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| Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow1: |
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| DefDC7: Off |
| Deficiencies and Comments cont Indicate all equipment devices and parts that were repaired or replacedRow2: |
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| DefDC27: Off |
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| CheckboxDeficiencies: Off |
| DeficiencyNumberAttached: |
| CheckboxAES10: Off |
| AES10Number Attached: |
| CB1stAnnual: Off |
| CB2ndAnnual: Off |
| CB3rdAnnual: Off |
| CB4thAnnual: Yes |
| Date1stQtr: |
| Date2ndQtr: |
| Date3rdQtr: 8/22/23 |
| Date4thQtr: 9/30/24 |
| Print Name: |
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| Signature: |
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File details come from the government source that posted it. Updated .