Attachment_5__CA_-_Clean_Agent_and_CO2_Test_Form_(1).pdf

Clean Agent or CO2 System Page 1 of 4 Revised 12/17/25

National Park Service / AKRO

Inspection and Test Report (complete a separate form for each system)

CLEAN AGENT OR CO2 SYSTEM – CLEAN AGENT CO2

Park Alpha Code: ______________________ FMSS Location No.:___________________

Location Description: ______________________

Date of Test:_________________________

Time:_________________

System Make: ______________________ System Model: _____________________

No of Cylinders ______________________ No. of Nozzles _____________________

Control Panel Make ______________________ Panel Model _____________________

DEFICIENCIES FOUND? Yes No List items that were not corrected. Use the Deficiencies section or attach itemized sheet

REPAIRS: All deficiencies have been corrected N/A Yes No

This certifies that the fire and life safety system has been inspected and tested for functional operation in accordance with applicable NFPA 2001 & 12 standards and has been properly tagged and/or labeled. Any discrepancies found are noted in this report with code references for corrective action by the Owner/Responsible Person.

Technician Name (printed): ______________________ Company: ______________________________

Signature: ___________________________________ Phone #: _______________________________

State Certification No.: _________________________

National/NICET No.: ___________________________

ENCLOSURE INTEGRITY

1. After visual inspection, there are no unsealed penetrations in walls, ceiling, and floors that would affect enclosure integrity.

Yes No

2. Doors in the protected enclosure are self-closing and provided with sweeps/gaskets Yes No

3. HVAC penetrations in the protected enclosure that could affect agent hold time are provided with low-leakage dampers.

Yes No

NOZZLES, PIPING, AND HOSE

4. All nozzles, piping, and brackets are properly placed and are secured. Yes No

5. All hose was visually inspected and does not have visual defects. Yes No

6. All hose five years old and older have been tested in 5-year intervals in accordance with NFPA 2001 Section 11.7. N/A’ for CO2 systems . Yes No

• Date for Next Hose Test: ___________ • •

7. All hose five years old and older has been tested in 5-year intervals in accordance with NFPA 12, Section 4.8.2. Yes No

Clean Agent or CO2 System Page 2 of 4 Revised 12/17/25

CYLINDERS AND EXTINGUISHING AGENT

8. The quantity loss is <5% and the pressure loss is <10% in each cylinder from the required quantity and pressure of the extinguishing agent.

Yes No

9. There is an up-to-date log containing a record of semi-annual checks for the agent quantity and pressure on each cylinder

Yes No

10. All cylinders with an unacceptable quantity loss were refilled or replaced.

N/A Yes No

11. All cylinders are tested and inspected according to NFPA 2001, Section 11.6.1 and 11.6.2 at the proper intervals.

Yes No

Date for next cylinder test____________

12. System passed actuating test without discharging carbon dioxide agent. Yes No

DETECTION AND CONTROL

13. All detection/initiating devices respond properly when tested.

No. of Units Tested Manual Stations ________________ Smoke Detectors ________________ Heat Detectors ________________ Air Sampling Detectors ________________ Tamper Switches ________________ Other ________________

N/A Yes No

14. All alarm functions take place upon receipt of a signal from the detection devices.

N/A Yes No

15. All alerting / notification devices work properly.

No. of Units Tested Pre Discharge Devices ________________ Post Discharge Devices ________________

16. All supervised circuits send the proper signals to the control panel. N/A Yes No

17. All manual release stations are readily accessible, accurately identified, and properly protected to prevent damage.

Clean Agent or CO2 System Page 3 of 4 Revised 12/17/25

RELEASE DEVICES

18. The automatic release device(s) work properly, including pre-discharge time delays.

19. All manual release stations used to release agents work properly. N/A Yes No

ABORT DEVICES

20. The manual abort switch is a dead-man type switch and functions properly.

AUXILIARY FUNCTIONS

21. All auxiliary functions such as alarm-sounding or displaying devices, remote annunciators, air-handling shutdown, damper operation, and power shutdown operate properly in accordance with system requirements and design specifications.

N/A Yes No

22. The alarms can be silenced, when allowed, without affecting other system functions.

SYSTEM MONITORING

23. The suppression control panel sends the proper signals to the building FACP.

N/A Yes No

24. The suppression control panel operates on standby power N/A Yes No

25. Signals were received at the monitoring company. N/A Yes No

TRAINING

26. All personnel working in enclosures protected by a clean agent system have received up-to-date training regarding clean agent safety issues.

Type of Extinguishing Agent ___________________

Agent Cylinders #1 #2 #3 #4 #5

Serial No. __________ __________ __________ __________ __________

PSI __________ __________ __________ __________ __________

Gross Weight __________ __________ __________ __________ __________

Agent Weight __________ __________ __________ __________ __________

Tare Weight __________ __________ __________ __________ __________

Liquid Level __________ __________ __________ __________ __________

Hydro Date __________ __________ __________ __________ __________

27. Cylinders passed hydrostatic tests. N/A’ . Yes No

Clean Agent or CO2 System Page 4 of 4 Revised 12/17/25

Deficiencies

Resolved

Location:

Deficiency:

Recommended Resolution:

NFPA reference: