Attachment_6__DC_-_Dry_Chemical_Test_Form_(1).pdf
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- Attached to
- AKRO STRCUTURAL FIRE SUPPRESSION & CONTROL EQUIP I Federal contract opportunity
- Solicitation number
- 140P9726Q0017
About this file
This is an Inspection and Test Report form used by the National Park Service Alaska Regional Office (AKRO) to document the inspection and testing of dry chemical suppression systems at park facilities.
The form certifies that fire and life safety systems have been inspected and tested for functional operation in accordance with NFPA 17 standards and properly tagged or labeled. The report captures system identification information including park alpha code, FMSS location number, location description, test date and time, system make and model, number of agent cylinders, and number of nozzles. The inspection evaluates five primary categories: Coverage, Nozzles, and Piping (5 items); System Controls (8 items); Cylinders and Extinguishing Agent (8 items); Monitoring (3 items); and Warning Signs (1 item). Each inspection item uses Yes/No/N/A checkboxes to indicate compliance status. The form requires documentation of any deficiencies found, whether repairs have been completed, and provides space for the technician's name, company affiliation, signature, phone number, state certification number, and National/NICET certification number. A deficiencies section on page three allows detailed documentation of any non-compliant items, including location, description of the deficiency, recommended resolution, and corresponding NFPA 17 references. The form is designed to be completed individually for each dry chemical suppression system inspected and was last revised on December 16, 2015.
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Text version
Dry Chemical Suppression System Page 1 of 3 Revised 12/16/15
National Park Service / AKRO
Inspection and Test Report (complete a separate form for each system)
DRY CHEMICAL SUPPRESSION SYSTEM
Park Alpha Code: ______________________ FMSS Location No.:___________________
Location Description: ______________________
Date of Test:_________________________
Time:_________________
System Make: ______________________ System Model: _____________________
No of Agent Cylinders ______________________ No. of Nozzles _____________________
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 NFPA 17, 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.: ______________________
COVERAGE , NOZZLES, AND PIPING
1. The area/hazard to be protected has the required number and type of nozzles to provide adequate fire protection.
Yes No
2. All nozzles are properly positioned. Yes No
3. Piping is installed and supported adequately with no evidence of damage Yes No
4. Fusible link cable conduits are immobilized with proper hangers and brackets. Yes No
5. At intervals not exceeding 12 years, hose assemblies passed hydrostatic pressure test.
Yes No
SYSTEM CONTROLS
6. All system controls and components are accessible and free from obstructions. Yes No
7. The system is operational from the test link (last fusible link) Yes No
8. All fusible links have been replaced and the year of manufacture and date of installation is marked on the system inspection tag.
Yes No
9. Manual release station(s) are readily accessible, located 42” – 48” above the floor, and identify the hazard they protect
Yes No
10. Manual release stations are configured correctly and operational. Yes No
11. The operation of the fusible link line is not impaired by debris or foreign materials. Yes No
12. Where the system protects a hazard with flowing flammable or combustible fluids or gases, an automatic means to shutoff the fuel upon operation of the extinguishing system is provided.
N/A Yes No
13. Equipment and/or fuel shutoff interlock(s) were tested and are operational N/A Yes No
Dry Chemical Suppression System Page 2 of 3 Revised 12/16/15
14. Warning signs are installed where there is a possibility that personnel could be exposed to a dry chemical discharge.
CYLINDERS AND EXTINGUISHING AGENT
15. The extinguishing agent in the cylinders conforms to the manufacturer’s requirements for this system.
Yes No
16. Storage cylinders are fastened securely to their mounting brackets. Yes No
17. The cylinders are filled with the correct volume of extinguishing agent.
Required volume ________lbs. or __________gals.
Yes No
18. The cylinder gauge is in the operational range. Yes No
19. The CO2 or Nitrogen cylinder is fully charged.
Design weight _____ lb. Actual Weight _____lb. N/A Yes No
20. The hydrostatic testing of the agent cylinder(s) is up-to-date.
Date for next hydrostatic test ______________________ N/A Yes No
21. Stored-pressure extinguishing systems cylinders that require a 12-year hydrostatic test have been emptied and examined internally and externally at 6-year intervals per NFPA 17, Section 11.3.1.2.
22. At intervals not exceeding 12 years, containers passed hydrostatic test. N/A Yes No
MONITORING
23. The system is connected to the fire alarm system. (if an alarm panel exists) N/A Yes No
24. The fire alarm panel receives the proper signals upon suppression system activation.
25. The alarm monitoring company received the alarm signal. N/A Yes No
Dry Chemical Suppression System Page 3 of 3 Revised 12/16/15
Deficiencies
Resolved
Location:
Deficiency:
Recommended Resolution:
NFPA 17 reference:
File details come from the government source that posted it. Updated .