S02 VAMC 5YrInsp-1st Floor.pdf

5-Year Inspection and Internal Pipe Assessment Form

Tag Minneapolis Inspection Frequency: Fifth Year Property Being Evaluated:

VAMC (Health Care) Owner:

Owner's Phone Number:

Property Address:

1 VETERANS DR, MINNEAPOLIS, MN, 55417-2309

1. General A. (To be filled out by the Owner or Owner's Representative) Has the Owners section been answered on another inspection report that will be submitted with this inspection report? Yes No

2. Five-Year Inspection Items

1. Check valve(s) internally inspected and all parts appear to operate properly, move freely, and are in good condition? Yes No N/A

2. Alarm valve(s) and their associated strainers and restricted orifices passed internal inspection? Yes No N/A

3. Strainers, filters, restricted orifices, and diaphragm chambers on Dry, Pre-Action, and/or Deluge valves passed internal inspection? Yes No N/A

4. Have known sprinkler heads exposed to harsh conditions (ie. Corrosive atmospheres, extreme temperatures, etc.) been tested/replaced? Yes No N/A

5. Have gauge(s) been replaced and dated? Yes No N/A

6. Performed pressure regulating device full flow test? Yes No N/A

7. Performed standpipe test? Yes No

3. Five-Year Assessment of Internal Condition of Piping The purpose of the assessment of the internal condition of piping is to provide a reasonable assurance that corrosion and obstruction issues within the fire protection system(s) are identified by opening a flushing connection at the end of one main and removing the end fitting, piece of branch line, or a sprinkler for the purpose of inspecting for the presence of foreign organic and inorganic material. It is not the intent to verify that every piece of pipe in the system is free from corrosion and obstructions.