Dry_Pipe_Annual_ITM_Form.pdf

Annual Inspection of Dry-Pipe Fire Sprinkler Systems (Form DS-1A)

Information on this form covers the minimum requirements of NFPA 25 (2020 edition) for fire sprinkler systems connected to distribution systems without supplemental tanks or fire pumps. Separate forms are available to inspect, test and maintain fire pumps and other fire protection systems. More frequent inspection, testing and maintenance may be necessary depending on the conditions of the occupancy and the water supply.

Building Name:

Building Number or Address: FMSS Asset ID No.:

Date of Work: All responses refer to the work (inspection, testing and maintenance) performed on this date.

Notes: 1) All questions are to be answered Yes, No, or Not Applicable. All No answers are to be explained.

2) Inspection, testing and maintenance are to be performed with water supplies (including fire pumps) in service, unless the impairment procedures of NFPA 25 and the appropriate NPS Job Plan are followed.

Part I – GENERAL

A. Is building occupied? Yes No

B. Has the occupancy classification and hazard of contents remained the same since the last inspection? Yes No

C. Are all fire protection systems in service? Yes No

D. Has the system remained in service without modification since the last inspection? Yes No

E. Was the system free from actuation of devices or alarms since the last inspection? Yes No

Part II – INSPECTION

A. Control valves:

1. In the normal (open or closed) position? Yes No N/A

2. Properly sealed, locked, or supervised? Yes No N/A

3. Accessible? Yes No N/A

4. Provided with appropriate wrenches? Yes No N/A

5. Free of external leaks? Yes No N/A

6. Provided with appropriate identification? Yes No N/A

7. Control valve supervisory alarm devices are free of physical damage? Yes No N/A

B. Dry-Pipe Valves:

1. Enclosures around valves maintaining a minimum of 40 F? Yes No N/A

2. Gauges in good condition showing normal air and water pressure? Yes No N/A

3. Free of physical damage? Yes No N/A

4. Trim valves in appropriate (open or closed) position? Yes No N/A

5. Intermediate chamber free of leakage? Yes No N/A

C. Dry-pipe valves passed internal inspection? Yes No N/A

D. For freezer systems, is the gauge near the compressor reading the same as the gauge near the dry-pipe valve? Yes No N/A

E. Backflow preventers supervised with seals:

1. Valves in correct (open or closed) position? Yes No N/A

2. Sealed, locked, or supervised and accessible? Yes No N/A

3. Relief port on RPA device not discharging? Yes No N/A

F. Pressure Reducing Valves:

1. In open position? Yes No N/A

2. Free of leaks? Yes No N/A

3. Maintaining downstream pressure per design criteria? Yes No N/A

4. In good condition with handwheels not broken? Yes No N/A

G. Hydraulic nameplate (calculated systems) securely attached to riser and legible? Yes No N/A

H. Fire Department Connections:

1. Visible? Yes No N/A

2. Accessible? Yes No N/A

3. Couplings and swivels not damaged and rotate smoothly? Yes No N/A

4. Plugs or caps in place and undamaged? Yes No N/A

5. Identification signs in place? Yes No N/A

6. Check valve is not leaking? Yes No N/A

7. Clapper is in place and operating properly? Yes No N/A

8. Automatic drain valve is in place and operating properly? Yes No N/A

(If plugs or caps are not in place, inspect interior for obstructions.)

I. Alarm devices free of physical damage? Yes No N/A

J. Visible Sprinklers:

1. Free of corrosion and physical damage? Yes No N/A

2. Free of obstructions to spray patterns? Yes No N/A

3. Free of foreign materials including paint? Yes No N/A

4. Liquid in all glass bulb sprinklers? Yes No N/A

K. Proper number and type of spare sprinklers? Yes No N/A

L. Sprinkler wrench with spare sprinklers? Yes No N/A

M. Visible Pipe:

1. In good condition/no external corrosion? Yes No N/A

2. No mechanical damage and no leaks? Yes No N/A

3. Properly aligned and no external loads? Yes No N/A

N. Visible pipe hangers and seismic braces not damaged or loose? Yes No N/A

O. Must be done before cold weather:

1. Adequate heat in areas with wet piping? Yes No N/A

2. Low temperature alarms functioning? Yes No N/A

3. Interior of pipe that passes through freezers free of ice blockage? Yes No N/A

Part IIa – FIFTH YEAR ONLY INSPECTION

A. Strainers, filters, restricted orifices and diaphragm chambers on dry-pipe valves passed internal inspection? Yes No N/A

B. Check valves internally inspected and all parts operate properly, move freely, and are in good condition? Yes No N/A

C. Internal inspection of the pipe performed by removing the flushing connection and one sprinkler near the end of a branch line? Yes No N/A

Part III – TESTING

A. Valve supervisory switches indicate movement? Yes No N/A

B. All control valves operated through full range and returned to normal position? Yes No N/A

C. Post indicating valves opened until spring or torsion is felt in the rod, then closed back one-quarter Yes No N/A turn?

D. Is the priming level correct and has the low air pressure signal passed its test? Yes No N/A

E. Quick opening devices passed test? Yes No N/A

F. Dry-pipe valve partial flow trip test:

1. Record initial air pressure psi and water pressure psi.

2. Record tripping air pressure psi and tripping time (sec.).

3. Record water delivery time (min.) (sec.).

Water delivery time not required to be 60 sec. Per NFPA 25

4. Above results comparable to previous tests? Yes No N/A

G. Automatic air maintenance devices passed test? Yes No N/A

H. Backflow devices passed full flow test? Yes No N/A

I. Backflow devices passed backflow test? Yes No N/A

J. Pressure reducing valves passed partial flow test? Yes No N/A

K. Waterflow alarm devices passed tests by opening inspector’s test connection or bypass connection Yes No N/A with alarms actuating and flow observed?

L. Main drain test:

1. Record Static Pressure psi and Residual Pressure psi.

2. Was flow observed? Yes No N/A

3. Are results comparable with previous test? Yes No N/A

M. Are all sprinklers dated 1920 or later? Yes No N/A

N. Fast response sprinklers 20 or more years old replaced or successfully sample tested within last Yes No N/A 10 years?

O. Standard response sprinklers 50 or more years old replaced or successfully sample tested within Yes No N/A last10 years?

P. Standard response sprinklers 75 or more years old replaced or successfully sample tested within Yes No N/A last 5 years?

Q. Dry-type sprinklers replaced or successfully sample tested within last 10 years? Yes No N/A

Part IIIa – THIRD YEAR ONLY TESTING

Dry-pipe full flow trip test:

A. Record initial air pressure psi and water pressure psi.

B. Record tripping air pressure psi and tripping time (sec.).

C. Record water delivery time (min.) (sec.).

Water delivery time not required to be 60 sec. Per NFPA 25

D. Above results comparable to previous test? Yes No N/A

Part IIIb – FIFTH YEAR ONLY TESTING

A. Gauges checked by calibrated gauge or replaced? Yes No N/A

B. Pressure reducing valves passed full flow test? Yes No N/A

C. Sprinklers rated above High temperatures tested? Yes No N/A

Part IV – MAINTENANCE

A. Operating stem of all OS&Y valves lubricated, completely closed, and reopened? Yes No N/A

B. Dry-pipe systems maintained in dry condition? Yes No N/A

C. Air leaks in dry-pipe systems resulting in air pressure loss more than 10 psi/week repaired? Yes No N/A

D. Interior of dry-pipe valves cleaned? Yes No N/A

E. Low points drained prior to the onset of freezing weather? Yes No N/A

F. If sprinklers have been replaced, were they proper replacements? Yes No N/A

G. Sprinklers and spray nozzles protecting commercial cooking equipment and ventilating systems Yes No N/A replaced except for bulb-type, which show no signs of grease buildup?

H. If any of the following were discovered, was an obstruction investigation conducted? Yes No N/A

Explain reason(s) and obstruction investigation findings in Part V.

1. Defective intake screen on pump with suction from open sources? Yes No N/A

2. Obstructive material discharged during waterflow tests? Yes No N/A

3. Foreign materials found in dry-pipe valves, check valves, or pumps? Yes No N/A

4. Foreign material in water during drain test or plugging of inspector’s test connection? Yes No N/A

5. Plugging of pipe or sprinklers found during activation or alteration? Yes No N/A

6. Failure to flush yard piping or surrounding mains following new installation or repairs? Yes No N/A

7. Record of broken mains in the vicinity? Yes No N/A

8. Abnormally false tripping of dry-pipe valves? Yes No N/A

9. System is returned to service after an extended period out of service (greater than one year) Yes No N/A

10. There is reason to believe the system contains sodium silicate or its derivatives or highly Yes No N/A corrosive fluxes in copper pipe systems?

I. If conditions were found that required flushing, was flushing of system conducted? Yes No N/A

Part V – ADDITIONAL COMMENTS (Any additional comments, test failures or other problems found with the sprinkler system must be explained here. Also, note here any products noticed on the systems that have been the subject of a recall or a replacement program.)

Part VI – SIGNATURES

Contractor Information (complete if work performed by Contractor)

Inspector/Technician:

Company:

Company Address:

Company Phone:

I state that the information on this form is correct at the time and place of my inspection, and that all equipment tested at this time was left in operational condition upon completion of this inspection except as noted in Part V above.

Signature of Inspector/Technician: Date:

License or Certificate Number (if applicable):

NPS Information (complete if work performed by NPS Employee)

Employee’s Name:

Division:

Phone Number:

I state that the information on this form is correct at the time and place of my inspection, and that all equipment tested at this time was left in operational condition upon completion of this inspection except as noted in Part V above.

Employee’s Signature: Date: