B08_Attachment_9_-_Fire_Sprinkler_Test_Form.pdf

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National Park Service / AKRO Inspection and Test Report (complete a separate form for each system)

FIRE SPRINKLER SYSTEM – DRY PIPE WET PIPE PREACTION RESIDENTIAL

Park Alpha Code: ________

Location Description : ______________________

Date of Test:_________________________ Time:_________________

Riser Valve Make: ______________________ Valve Model: _____________________ Size: ____________________ Serial No: _____________________

Off Site Monitoring? Yes No Monitoring Company or Location

Name ________________________________

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 the current edition of NFPA 25 and NFPA 13, 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.: ___________________________

GENERAL

1. Sprinkler coverage was inspected and is adequate Yes No

2. Sprinkler heads are not blocked or obstructed Yes No

3. Piping is adequately installed with no bent or visibly damaged piping Yes No

4. Hangars and bracing components are not missing or damaged Yes No

5. A backflow preventer is provided and is accessible for maintenance N/A Yes No

6. Sprinkler heads are provided 18” min. clearance above top of storage N/A Yes No

7. Hydraulic design placard is installed and visible on riser N/A Yes No

SPRINKLER HEADS

8. Number of Sprinkler Heads: <20 >20 but < 100 >100

9. All accessible sprinkler heads have been visually inspected and are free of corrosion, paint, obstructions and/or physical damage. (If “no”, list the location of any defective heads in the “Deficiencies” section.)

Yes No

10. Standard Response sprinkler heads are less than 50 years old and do not require sample testing or replacement.

N/A Yes No

11. Fast Response sprinkler heads (quick response and residential) are less than 20 years old and do not require sample testing or replacement.

N/A Yes No

12. Dry type sprinkler heads are less than 10 years old and do not require sample testing or replacement

N/A Yes No

Karma Torres Text Box Asset No.:

Karma Torres Line

Karma Torres Snapshot

Karma Torres Line

Karma Torres Line

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13. The proper number of spare sprinkler heads is available, with the proper wrenches for each, at the riser or another designated location.

Yes No

FLOW TESTS

14. The system main drain is the proper size and discharges to the exterior of the building.

Size of drain _______ Required size ________

Yes No

15. A Main Drain flow test was performed:

Static pressure ____ psi Flow pressure ____ psi Return to static pressure ____min/sec

Yes No

16. Flow from the inspector’s test valve activates the system alarms within 60 seconds. Yes No

ALARMS AND SUPERVISORY DEVICES

17. All supervisory and alarm devices [i.e. bell(s), flow switches, high/low air switches, valve tamper switches] function properly.

N/A Yes No

18. A water motor gong/bell is provided on the exterior of the building N/A Yes No

VALVES

19. All system supply and control valves are secured or supervised in the open position. Yes No

20. All supply valves have been lubricated (OS&Y valves) N/A Yes No

GAUGES

21. The maintenance on system gauges is up-to-date. Every 5 years, installed gauges shall be checked against (1) calibrated gauge to determine accuracy. If not within 3% of the calibrated gauge it should be replaced or recalibrated.

Due date for the next comparison test: ____________

Yes No

OBSTRUCTION INVESTIGATION

22. A 5-year obstruction investigation was performed per NFPA 25.

Date for next obstruction investigation _____________

Yes No

FIRE DEPARTMENT CONNECTIONS

23. The Fire Department Connection(s) (FDC) is clear of bushes, guards, or other debris and is visible from the fire access road

N/A Yes No

24. FDC inlets have protective caps or covers. (Note: If missing, the pipe shall be visually inspected for debris)

N/A Yes No

25. FDC inlets have at least 12” clearance for operating wrenches. N/A Yes No

ALARM MONITORING

26. All signals were received by the fire alarm system and the monitoring company.

N/A Yes No

DRY PIPE SYSTEM

27. The dry pipe valve was trip tested per NFPA 25. System tripped at _______ psi.

N/A Yes No

28. Water was discharged from the inspector’s test connection within 60 seconds of opening the test valve (“full trip test”). Must be performed every 3 years. Water delivery was _______ seconds, or Date of last full trip test:

N/A Yes No

29. Air compressor refills system in 30 minutes or less. N/A Yes No

30. The system’s low points were drained and the system was restored to service.

N/A Yes No

31. A quick opening device (QOD) is used (accelerator or exhauster) N/A Yes No

PREACTION SYSTEM

32. Heat actuation devices were functionally tested. N/A Yes No

ANTIFREEZE Record high and low point glycol readings at the bottom of page 3

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33. Antifreeze solution has been inspected and checked N/A Yes No

34. Premixed antifreeze solution is used N/A Yes No

PRESSURIZED WATER STORAGE TANK

35. Water level is within the normal range Yes No

36. Heating system is functional N/A Yes No

37. Exterior inspection of tank structure, supports, vents, and outlets, shows no evidence of accelerated corrosion or damage.

Yes No

38. Interior inspection was performed and shows no evidence accelerated corrosion, pitting, debris, or biological growth. (required at 3 year intervals)

N/A Yes No

39. All supply valves are open Yes No

40. Air or nitrogen pressure and quantity is adequate N/A Yes No

RECALLS

41. The technician did not find recalled devices or equipment during the visual inspection.

Yes No

ANTIFREEZE: . . Glycol high point measurement . . Glycol low point measurement

. . Glycol freeze protection temperature in degrees F

Where glycol freeze protection is determined to be above -20 deg F, the contractor must contact the COR immediately following the site visit to determine whether a contract modification is required to refill the systems with an approved -25 deg F (or greater) NFPA product.

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Deficiencies

Resolved

Location:

Deficiency:

Recommended Resolution:

NFPA 25 or NFPA 13 reference:

Resolved

Location:

Deficiency:

Recommended Resolution:

NFPA 25 or NFPA 13 reference:

Resolved

Location:

Deficiency:

Recommended Resolution:

NFPA 25 or NFPA 13 reference:

Resolved

Location:

Deficiency:

Recommended Resolution:

NFPA 25 or NFPA 13 reference:

Resolved

Location:

Deficiency:

Recommended Resolution:

NFPA 25 or NFPA 13 reference: