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_ Ahern Fire Protection Annual S rinkler
I ® 13705 26th Avenue, Suite 110 p Work Order #:
Minneapolis, MN 55441 System Inspection 854164
n (763) 268 -0515 p • (763) 268 -0516 f For Month/Year:
1 HER'N www.ahernfire.com • Since 1880 Report August 2011
Invoice: HOLIDAY COMPANIES
Street: 4567 AMERICAN BLVD
Phone #: (952) 830 -8700
City: BLOOMINGTON State: MN Zip: 55437
Location: Holiday Store #391 Dept.:
Street: 4460 Fountain Hills Drive
Phone #: (952) 403 -0377
City: Prior Lake State: MN Zip: 55372
Fax #: Foreman: Jesse Olmanson
Date: fr'' Signature: -„ ».'
V l' --
Wet 1 Foam FireDoors Suppression BF RP
Dry 1 Alarms FirePumps _ Anti _ Freeze _ -__ BF DC
Preaction Detectors ValveTT 1 Water Spray BF Generic
Deluge Hydrants BF Lincoln
Stand Pipe/Hose Internal Sprinkler BF Omaha
Contacts: Steve Reckinger Direct: (952) 830 -8700 Ext: Direct: Ext:
Invoice/Deficiency Cell/Pager: Cell/Pager:
IALARM DEVICES TESTS Y N N/A I
1. Did waterflow or pressure switches operate satisfactorily? ❑ ❑
2. Did tamper switches operate satisfactorily? ❑ ❑
3. Did water motor alarm gongs or electric bells operate satisfactorily? ❑ ❑
4. Did alarm service or central station operate satisfactorily and receive proper signals? - ❑ ❑
(ALARM SIGNALS I
System # V C - -' t
Test Times - 7 7 S e- r
15 YEAR INSPECTION Y N N/A I
1. Was the 5 year Inspection performed on the following items? ❑ V
A. Alarm valves
B. Check valves
C. Gauges
D. Internal Examination of Piping Date due: ❑ ❑ ❑
I5 -YEAR TESTING Y N N/A I
1. Was the 5 year testing performed on the following items? ❑ ❑
A. Sprinkler heads in corrosive environments or rated 325° F or higher. Date Due: ❑ ❑ ❑
B. Standard sprinklers in service for 75+ years. Date Due: ❑ ❑ ❑
110 -YEAR TESTING Y N N/A
1. Was the 10 year testing performed on the following items? ❑ N c ❑
A. Standard sprinklers in-service for 50+ years. Date Due: E Ir ❑
B. Quick response sprinklers in service for 20+ years. Date Due: ❑ ❑ ❑ .
C. Dry pendant sprinklers. Date Due: ❑ ❑ ❑
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" LID 11: 3150149 Page 2 of 3
'CONTROL VALVE SERVICE - I. "" Y N N/A
1. Were the following service items performed on all control valves? N ❑
A. Fully opened and closed? N ❑ ❑
B. Valve packing checked?
C. Valve stem lubricated?
D. Is the valve properly secured and locked in its normal operating position? 0 0
(BACKFLOW PREVENTOR TEST Y N N/A I
1. Did the backflow preventor(s) pass the test of backflow and forward flow capabilities? ❑ ❑ k
N (ANTI- FREEZE TEST Y N N/A I
1. Has the anti -freeze solution for each system below been tested by measuring specific gravity? ❑ ❑
(HANGERS AND SEISMIC BRACING Y N N/A I
1. Did hangers and seismic bracing appear to be in good condition, firmly attached, and free from corrosion, from a visual inspection
performed from floor level? fi 0 0
(PIPING Y N N/A I
1. Was the exterior of exposed sprinkler piping in good condition, not subjected to external loads, free of mechanical damage? \ E E
NOTE: Piping located in concealed spaces, such as above a drop ceiling, are not required to be inspected
'FIRE DEPARTMENT CONNECTIONS Y N N/A I
1. Are fire department connections visible and in good condition? N ❑ 0
2. Are caps and plugs in place? ❑ E
3. Are automatic drain valves operating properly? ❑ 7
4. Do hose connections operate freely? 7 n
I HOSE RACKS PRESENT? 0 Yes No CONDITION: 0 Good L_ Fair l3ad Y N N/A
'MAIN DRAIN TEST I
System Number /r f / _ ,
Static Pressure m� a
maim
1
Residual Pressure g
Size of drain
•
1. Were all main drains tested at full flow? _ \ ❑
If no, explain:
2. Were test results similar to the last test? ` Y ❑ ❑
If no, explain: -
3. Was there any discharge of obstructive material, heavy discoloration of water, or plugging of the inspector's test connection? — 1cl ❑
'GENERAL INFORMATION Y N N/A 1
1. Are all the sprinkler systems in service? " E " E
2. Is the building completely sprinklered? - 0 ❑
3. Are all sprinklers in good condition? 0 ❑
4. Are all sprinklers free of obstruction? 0 0
5. Are spare sprinklers and wrenches available? ❑ ❑
y , 4. In spray coating area, are sprinklers free from accumulation? `�I
7. Is hydraulic nameplate and information sign securely in place and legible? ❑
8. Is emergency service contact information readily available?
9. Are alarm devices provided and in good condition? \ ❑ 0
10. Are all standard sprinklers dated 1920 or later? ❑ 0
'OWNER QUESTIONS Y N N/A I
1. Any changes in sprinkler system since last inspection? II k 0
2. Any fires since last inspection? 0 ❑
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"' LID #: 3150149 Page 3 of 3
A. Number of sprinkler heads that operated. '
B. How long was system out of service?
C. Area where fire occured. _.
3. Are all areas of the building properly heated to prevent free zing where wet pipe systems exist? ICI ❑ ❑
4. Do you have an outside alarm service? N ❑ E
If yes, name and phone number.
Note to Owner - Our inspections will only report conditions as they exist at time of inspection and do not guarantee the operation of the
System due to factors beyond our control. (i.e., potentially closed valves or depleted municipal water supply.) Per NFPA -25, this inspection is
based on the assumption that the system has been installed in accordance with all applicable codes and standards.
Owner /Representative's Signature: Date
New Deficiencies found during this inspection? Yes ( No ' Customer receive copy of New Deficiency Report? Yes No
1. _
INOTES I
on site mgr Rick
SERVICES PERFORMED: 0 Alarm Test 0 Drain Test U Flow Test 0 Walk Through Annual Inspection 0 Other
This document PROPERTY OF AHERN FIRE PROTECTION. Copyright 2005 J.F. Ahem Co. REPRODUCTIONS IN ANY FORM VIOLATES COPYRIGHT. rptlnspection_Annual
• Ahern Fire Protection Dry /Preaction/
13705 26th Avenue, Suite 110 I Date: 8/1/2011
Minneapolis, MN 55441 Deluge Pipe Work Order #:
(763) 268 -0515 p • (763) 268 -0516 f 854164
HERN www.ahernfire.com •Since 1880 Valve Trip Test LID #: 3150149
Location: Holiday Store #391 Dept.:
Street: 4460 Fountain Hills Drive City: Prior Lake State: MN Zip: 55372
Phone #: (952) 403 -0377 Fax #: Foreman: Jesse Olmanson
Date: r+ ' ^ ^— d // Signature: ! System #:
#:
System Type: Dry
Valve Serial #:
Manufacturer Name: Central
Valve Model: 3 fxf
Valve Size: 3
Controlling Sprinklers Location: attic
Controlling Sprinklers Number: approx.
Date of Last System Pressure Test:
(Must be done every 3rd Year)
Date of Last Full -Flow Trip Test:
(Must be done every 3rd Year) r
Date Last Operated:
Pressure Before Test - Air 1 10 lbs.
Pressure Before Test - Water / C) lbs.
Size and Location of Test Valve:
Was gate valve below dry valve opep wide at test? (if not, how many tums ?)
Valve Tripped At - Air pressure Gam-) lbs.
Valve Tripped At - Water Pressure lbs.
Valve Tripped At - Time min. ` sec.
If system flooded, list time water reached test opening. min sec.
PERFORMANCE Poor Fair Good
Interior of Body Poor Fair Good
Moving Parts Poor Fair Good
Rubber Facing Poor Fair Good
Seats Poor Fair' Good
Reset? Yes No N/A
Did alarms operate at trip test? r Yes No N/A
Have low point drains been emptied? # 1 Yes No N/A
Water control valve left open and sealed? Yes No N/A
Are the valves accessible? Yes No N/A
ar Arethe valve enclosures heated adaquately? Yes No N/A
Interior of pipe that passes through freezers
free of ice blockage? Yes No N/A
Quick Opening Devices
Device Serial #:
Device Manufacturer Name:
Device Type and Model:
Air pressure in upper chamber Ib,.
Quick opening device tripped at sec. Ib,
Quick opening device left in service, and control open and sealed?
Yes No N/A
AIR COMPRESSOR C Plant O System ■ Manual Automatic
Oil Level? Add Oil? Belt Tight? Belt Conditions?
Cuts In? lbs. Cuts Out? lbs. Tested? Reset? Yes No N/A
Page 1 of 1 This document PROPERTY OF AHERN FIRE PROTECTION. Copyright 2008 1.F. Ahern Co. REPRODUCTIONS IN ANY FORM VIOLATES COPYRIGHT. rptValveTripTest