Attachment C - Sprinkler System Test Form.pdf

SYSTEM #

WET FIRE SPRINKLER SYSTEM

UFC INSPECTION AND TESTING REPORT

Date Building

Time Address

Inspector City, State, Contact Phone

Monitoring Entity Company Phone Account

Authority Having Jurisdiction Name Phone Service: 2YR 5YR 10YR 20YR 50YR

Yes No N/A 2 YEAR, Control Valves, operate valve through entire travel to verify function.

2 YEAR, Control Valves, lubricate valves and stems to ensure operability.

5 YEAR, Alarm Valve, clean and inspect internally to verify condition.

5 YEAR, Anti-Freeze Loops, confirm correct solution mixture.

10 YEAR, Gauges, recalibrate or replace gauges.

20 YEAR, Fast Response Sprinklers and Extra High Temp Sprinkler, test a sample to verify response characteristics 50 YEAR, Standard Sprinkler, replace or test a sample to verify response characteristics.

System riser location Size Make Model Waterflow test results Main Drain Size Static Residual Restore Antifreeze system solution test results? Degrees Problems Found:

Corrections Made:

Comments:

This Testing Was Performed In Accordance With Applicable Standards

Inspector Certificate Date Time

Inspector Signature

Site Representative Date Time

Signature