Atch 5 - KH Report - Sample Report.pdf

Wet Chemical Pre-Engineered Fire Extinguishing System

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

Semi-Annual Report 1 of 2

Property Information Contractor or Licensed Owner Information

Building Name Name Address Address

City St. Zip City License # Phone Contact Person SFM Job # Phone CSLB Misc.

System Information Cylinder Size Last Hydrostatic Test Date Flow Points Capacity Used System Location System Mfr. Model # Fuel/Heat Shut Off:

Gas # Electrical # Integral Make Up Air Shut Down

Items # of Items Dimensions Nozzle Model #

Nozzle Flow Points

Nozzle Qty

Total Flow Points

Hoods Plenums Ducts

Cooking Appliances Left to Right with Sizes and Coverage Nozzles

Appliance Name Nozzle Model

Nozzle Flow Points

Total Flow Points Appliance Name Nozzle

Model Nozzle

Flow Points Total

Flow Points

Fixed Temperature Sensing Elements (Such as Fusible Links)

Quantity Temp Mfr Date

Install Date Quantity Temp Mfr

Date Install Date

Inspection, Testing, and Maintenance I = Inspection T = Test M = Maintenance P = Pass F = Fail N/A = Not Applicable

Item Description NFPA 17A CA

ed. Reference Date Comments Only P,F,N/A

1.1 I Manual Actuators are Unobstructed

(i.e. Remote Pull Station) 7.2.2(2)

1.2 I Tamper Indicators & Seals Intact 7.2.2(3)

1.3 I Maintenance Tag in Place 7.2.2(4)

Title 19 §906

1.4 I No Obvious Physical Damage 7.2.2(5)

1.5 I Gauge Readings within Proper Limits

(Stored Pressure) 7.2.2(6)

1.6 I Blow-Off Caps in Place & Undamaged 7.2.2(7)

1.7 I Hoods, Ducts, Filters in Place and Clean CFC 904.11.6.3

1.8 I Hood, Ducts & Protected Cooking Appliances Have

Not Been Replaced, Modified or Relocated 7.2.2(8)

2.1 T Automatic Detection/Manual Actuation Functioned

Correctly 7.3.3.4

Form AES 20 Sept. 3, 2013

Wet Chemical Pre-Engineered Fire Extinguishing System

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

Semi-Annual Report 2 of 2

Property Information Contractor or Licensed Owner Information

Building Name Name

Address Job #

City

Inspection, Testing, and Maintenance I = Inspection T = Test M = Maintenance P = Pass F = Fail N/A = Not Applicable

Item Description NFPA 17A CA

ed. Reference Date Comments Only P,F,N/A

2.2 T Fuel Shut-Off Operated Correctly 7.3.3.4

2.3 T Regulator Tested & is within Acceptable Limits 7.3.3.4

2.4 T Manual Reset Relay Functioned Correctly

(If Applicable) 7.3.3.4

3.1 M All Agent Containers within Acceptable Hydrostatic

Test Dates 7.5.1(1)

3.2 M All Auxiliary Pressure Containers and/or Hose

Assemblies within Acceptable Hydrostatic Test Dates 7.5.1(2)(3)

3.3 M Cartridge Weights within Acceptable Limits 7.3.3.1(2)

3.4 M Liquid Level within Acceptable Limits

(Non-pressurized) 7.3.3.1(2)

3.5 M No Signs of Corrosion in Agent Cylinder

(Non-pressurized) 7.3.3.1(2)

3.6 M Distribution Piping Unobstructed and Contiguous 7.3.3.1(3)

3.7 M Nozzles are Correct, Clean & Properly Aimed 7.3.3.1(2)

3.8 M FL[HG THPS FXVLEOH MHWDO AOOR\ T\SH 'HWHFWRUV RHSODFHG 7.3.4

3.9 M Fixed-Temp (Other Than Fusible Metal Alloy Type) &

Heat Detectors Maintained or Replaced 7.3.5

3.10 M Auxiliary Equipment Such as Water valves

Functioned Correctly 7.3.3.1(2)

3.11 M Internal Maintenance as Required by Manufacturer Title 19 §904.7

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

Check here if additional Deficiencies and Comments are listed on Form AES 9�

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

Form AES 20 Sept. 3, 2013