36C77019R0004-022.pdf

SYSTEM RECORD OF INSPECTION AND TESTING

This form is to be completed by the system inspection and testing contractor at the time of a system test.

It shall be permitted to modify this form as needed to provide a more complete and/or clear record.

Insert N/A in all unused lines.

Attach additional sheets, data, or calculations as necessary to provide a complete record.

Inspection/Test Start Date/Time: 2018-08-25 Inspection/Test Completion Date/Time: 2018-08-25

Supplemental Form(s) Attached: Yes (yes/no)

1. PROPERTY INFORMATION

Name of Property: CMOP

Address: 5000 S. 13th

Description of property:

Name of property representative: Tony Crisp

Address:

Phone: (913) 727-4831 Fax: Email: tony.crisp@va.gov

2. TESTING AND MONITORING INFORMATION

Testing organization: Keller Fire & Safety

Address: 1138 Kansas Ave, Kansas City

Phone: (913) 371-8494 Fax: Email: info@kellerfire.com

Monitoring organization: Alarm Central

Address: 5510 East 31st Street

Phone: (816) 861-1500 Fax: Email:

Account number: F9-449 Phone line 1: Phone line 2:

Means of transmission: Digital

Entity to which alarms are retransmitted: Alarm Central Phone:

3. DOCUMENTATION

On-site location of the required record documents and site-specific software: Office

4. DESCRIPTION OF SYSTEM OR SERVICE

4.1 Control Unit

Manufacturer: Bosch Model Number: D7024

4.2 Software and Firmware

Firmware revision number: 1.04

4.3 System Power

4.3.1 Primary (Main) Power

Nominal voltage: 120 Amps: 20A Location: Panel P8

Overcurrent protection type: Amps: 20A Disconnecting means location:

4.3.2 Secondary Power

Type: BAT Location: In Panel

Battery type (if applicable): SLA

Calculated capacity of batteries to drive the system:

In standby mode (hours): 24 In alarm mode (minutes): 5

2018/08/25

SYSTEM RECORD OF INSPECTION AND TESTING (continued)

5. NOTIFICATIONS MADE PRIOR TO TESTING

Monitoring Organization Contact: Central station Time: 08:00

Building Management Contact: Tony Time: 08:00

Building Occupants Contact: All Time: 08:00

Authority Having Jurisdiction Contact: Time:

Other Contact: Time:

6. TESTING RESULTS

6.1 Control Unit and Related Equipment

Description Visual Inspection Functional Test Comments

LCD See Attached

CPU See Attached

Lamps/LED's See Attached

Fuses See Attached

Trouble Signals See Attached

Disconnect Switches See Attached

Ground Fault Monitoring See Attached

Circuit Supervision See Attached

Isolation Modules See Attached

Primary Power Supply See Attached

Secondary Power Supply See Attached

System Cards See Attached

Amplifiers See Attached

6.2 Secondary Power

Description Visual Inspection Functional Test Comments

Battery condition See Attached

Load voltage See Attached

Discharge test N/A

Charger test N/A

Remote panel batteries N/A

6.3 Alarm and Supervisory Alarm Initiating Device

Attach supplementary device test sheets for all initiating devices.

6.4 Notification Appliances

Attach supplementary appliance test sheets for all notification appliances.

6.5 Interface Equipment

Attach supplementary interface component test sheets for all interface components

Circuit Interface / Signaling Line Circuit Interface / Fire Alarm Control Interface

6.6 Supervising Station Monitoring

Description Yes No Time Comments

Alarm Signal

Alarm Restoration

Trouble Signal

Trouble Restoration

Supervisory Signal

Supervisory Restoration

6.7 Public Emergency Alarm Reporting System

Description Yes No Time Comments

Alarm Signal

Alarm Restoration

Trouble Signal

Trouble Restoration

Supervisory Signal

Supervisory Restoration

7. NOTIFICATIONS THAT TESTING IS COMPLETE

Monitoring Organization Contact: Central station Time: 10:00

Building Management Contact: Tony Time: 10:00

Building Occupants Contact: All Time: 10:00

Authority Having Jurisdiction Contact: Time:

Other Contact: Time:

8. SYSTEM RESTORED TO NORMAL OPERATION

Date: 2018-08-25 Time 10:00

9. CERTIFICATION

This system as specified herin has been inspected and tested according to NFPA 72, 2013 edition, Chapter 14.

Signed: Printed name: Connor Robinson Date: 2018-08-25

Organization: Keller Fire & Safety Title: Technician Phone: (816) 824-5347

Qualifications (refer to 10.5.3): Technician

10. DEFECTS OR MALFUNCTIONS NOT CORRECTED AT CONCLUSION OF SYSTEM INSPECTION,

TESTING, OR MAINTENANCE

(See Attached)

10.1 Acceptance by Owner or Owner's Representative:

The undersigned accepted the test report for the system as specified herein:

Signed: Printed name: Tony Crisp Date: 25-08-2018

Organization: CMOP Title: Phone: (913) 727-4831