HomeMy WebLinkAboutWet Pipe Fire Sprinkler System Inspection Report - 8/10/12 :-° � Zl�'"13
Form for Inspection, Testing and Maintenance of ��� ONFSA
Wet Pipe Fire Sprinkler Systems ���������
This form covers the minimum requirements of NFPA 25-2008 for wet pipe fire sprinkler systems connected to water supplies without
tanks or fire pumps. Separate forms are available for inspection, testing and maintenance of fire pumps, tanks, 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. The work covered on this form is (check one): ❑ Monthly ❑ Quarterly � Annual ❑ Third 5�ear ❑ Fifth Year
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Owner: ��,.L� S /� `S-��G Owner's Phone Number:
Owner's Address: M � �
Property Being Evaluated: � �
Property Address: �
Date of Work: - - All responses refer to the current 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 in Parf III of this form.
2) Inspeciion, Testing and Maintenance are to be performed with water supplies (including fire pumps) in service, unless the
impairment procedures of Chapter 15 of NFPA 25 are followed.
Part I- Owner's Section 3. Quarterly Inspection Items (continued)
A.Is the building occupied? � Yes � No c. Pressure reducing valves in open position, not leaking,
B. Has the occupancy and hazazd of contents with downstream pressure per design � teria, and in good
remained the same since the last inspection? Yes ❑ No condition with handwheels not broken. ❑ Yes C] No�j N/A
C.Are all fire prot�etion systems in service? �Yes ❑ No d. Hydraulic nameplate (calculated systems)
D.Has the system remained in serv�ce without � securely attached to riser and legible? � Yes ❑ No ❑ N/A
4. Annual Inspection Items (in addition to above items)
modification since the last inspection? � Yes ❑ No a. Proper number and type of spare sprinklers? J� Yes ❑ No 0 N/A
E. Was the system free of actuation of devices b. Visible sprinklers:
or alarms since the last inspection? � Yes ❑ No 1. Proper position (upright, pendent, sidewall)?�Yes ❑No ❑ N/A
F. Name and address of property insurance contacr 2. Free of corrosion and physical damage? �) Yes ❑ No ❑ N/A
G. Policy nurnber (i f k nown): 3. Proper clearance below sprinklers? 7 � Yes ❑ No 0 N/A
4. Free of foreign materials including paint. � Yes ❑ No a N/A
D i^ � � � UYrc ` 5. Liquid in all glass bulb sprinklers? Yes ❑ No ❑ N/A
: Owner or Representative (print name) Signature and Da c. Visible pipe: �
1. In good condition/no external corrosion. � Yes ❑ No ❑ N/A
Part II - IriSpeCtOr'S SeCtlOri 2. No mechanical damage or leaks? � Yes ❑ No O N/A
A. InspeCtions 3. No external loads? Yes O No ❑ N/A
L Daily and Weekly Items d. Visible pipe hangers and seismic braces
a. Control valves supervised with seals passed i pection not damaged or loose? ' � Yes ❑ No ❑ N/A
in accordance with II.A.2.a below? �Yes ❑ No ❑ N/A e. Hose, hose couplings and nozzles on spri er
b. Backflow preventers: systempassed inspection per NFPA 1962? ❑ Yes ❑ No�N/A
1. Accessible and isolation valves open? ❑ Yes ❑ No N/A f. Adequate heat in areas with wet piping? �Yes ❑ No ❑ N/A
2: Sealed, locked or supervised? ❑ Yes ❑ No N/A g. Internal inspection of the pipe performed in the
3. Relief port an RPZ not discharging? ❑ Yes 0 No N/A last 5 years (remove a flushing connection and
2. Monthly Inspeetion Items (in addition to above items) one sprinkler near the end of a branch line)? ❑ Yes �No O N/A
a. Control valves and valves on backflow (If `?Vo'; conduct internal inspection)
preventers with locks or electricai supervision: 5. Fifth Year Inspection Items (in addition to above items)
1. In correct (open or closed) position? 1�Yes a No 0 N/A a. Alarm valves and associated strainers, filters and
2. Lock or supervision in place? 7�] Yes ❑ No 0 N/A restricted orifices passed internal inspection?❑ Yes ❑ No�N/A
3. Accessible and free from externalleaks? � Yes ❑ No ❑ N/A b. Check valves internally inspected, all parts
4. Provided with appropriate wrenches?- � Yes ❑ No 0 N/A operate properly and are in good condition? ❑ YesJ� o O N/A
S. Provided with appropriate identification? �1 Yes ❑ No ❑ N/A a Internal pipe inspection performed per 4.g? ❑ Yes �No ❑ N/A
b. Sprinkler wrench with spare sprinklers? `�l Yes ❑ No I� N/A B. Testing
c. Gages on system in good condition and
showing normal water suppiy pressure? `� Yes ❑ No ❑ N/A Report any failures on Part III of this form.
d. Alarm valve free from physical damage, trim 1. Quarterly Tests
in conect (open or closed) position and no a. Mechanical waterflow alarm devicespassed
leakage from retarding chamber or drains? ❑ Yes ❑ No'� N/A tests by opening the inspector's test conn�ection
3. Quarterly Inspection Items (in addition to above items) with alarms actuating and flow observed. � Yes ❑ No ❑ N/A
a. Fire department connections visi b le, accessi b le, b. Post indicating valves opened until sp�ng or torsion
couplings and swivels not damaged, gaskets in felt in the rod then closed back /4 turn. ❑ Yes ❑ No�l N/A
place and in good condition, identification sign(s) c. Main drain test for system downstream of �backfl� d�� e or
in place, check valve is not leaking, clapper in place pressure reducing valve: '�j- U}�'� ��
and operating properly and automatic drain valve I� Q
in piace and operating properly? � Yes 0 No ❑ N/A 1. Record static pressure LYV psi, residual pressure� psi
(If plugs or caps are not in place, inspect interior or o }� ctions) 2. Was flow observed? '1� Yes ❑ No ❑ N/A
' b. Alarm devices free from physical damage? �Y�s �N a N/A�► �'`�`re results comparable to previous tests? � Yes �] No ❑ N/A
02009 National Fire Sprinkler Association, 40 Jon Barrett Road, Patterson, NY 12563 (845) 878-4200 Form 25-13W-08 Sheet 1 of 2
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2. 5emianoual Tests (in addition to prevtous items) 8. Abnormally frequent false-Mpping of dry-pipe valves
a. Valve supervisory switches indicate 9. System is retumed to service after an extended period of time
movement? �Yes 0 No ❑ N/A out of service (more than one year)
b. Electrical waterflow alann devices passed 10. There is reason to believe the system contains sodium silicate
tests by opening inspector's test connection or its derivatives or highly corrosive fluxes in copper pipe
with alarms actuating and flow observed? �Yes� No N/A g. If conditions were found that required
3. Annual Tests (iu addition to previous items flushing, was flushing of system conducted? ❑ Yes 0 No�'N/A
a. Main drain test for systems not tested quarterly: h. Was a drain test conducted after opening any
closed valves? ❑ Yes 0 No�N/A
1. Record Static�_psi and Residual Pressure �psf i. Adjusted, repaired, reconditioned or replaced components
2. Was flow observed? Yes O No O N/A had the associated tests and/or inspecrions required
3. Are results comparable to previous tests? Yes ❑ No O N/A by Table 5.5.1 of NFPA 25 performed? ❑ Yes C] No�N/A
b. Are all sprinklers dated 1920 or later? Yes ❑ No a N/A 2. Annual Maintenance Items (in addition to previous items)
c. Sprinklers with fast response elements 20 years a. Operaring stem of all OS&Y valves
old or more replaced or successfully sample lubricated, completely closed, and reopened? �Yes ❑ No ❑ N/A
tested in last l0 years? ❑ Yes O No ¢�N/A b. Sprinklers subject to recall replaced? ❑ Yes ❑ No�'N/A
d. Standard response sprinklers 50 years old or more replaced or c. Sprinklers and spray nozzles protecting
successfully sample tested in last 10 years? ❑ Yes O No 1� N/A commercial cooking equipment and ventilating
e. Standard response sprinklers 75 years old or more replaced or systems replaced except for bulb-type wluch
successfully sample tested in last 5 years? ❑ Yes O No � N/A show no signs of grease build-up? ❑ Yes ❑ No� N!A
f. Dry-type sprinklers replaced or successfully
sample tested in last 10 years? ❑ Yes �No a N/A Part III — Comments (Any `No"answers, testfailures or other
g. Antifreeze solution specific gravity: problems found with the sprinkler system must be explained here.
1. Correct at most remote point? ❑ Yes ❑ No N/A Also note here any products noticed on the system that have been the
2. Correct at interface with wet system? ❑ Yes O No N/A subject of a recall or replacement program.)
3. Correct at other test points (over 150 ga1)? OYes ❑ No N/A
h. All control valves operated through full range
and returned to normal position? � Yes 0 No ❑ N/A "�
i. Backflow devices passed backflow test? ❑ Yes O No N/A
j. Backflow devices passed forward flow test? O Yes 0 No N/A
k. Pressure reducing valves passed partial flow? OYes O No N/A �� �l� , e � ���� � S(� 8�.�
4. Test for every third year (in addiHon to previous items) �
Hose more than 5 years old connected to the system � t� � v-� �8 �,� ,�, � � � 3 s � j
has been service tested per NFPA 1962. Water ,r � �—
dischazged and water flow alarms operated7 ❑ Yes a No 1�N/A � 2 T G. .�. __
5. Tests for every fifth year (in addition to appropriate items)
a. Sprinklers above lrigh temperature tested? ❑ Yes 0 No N/A
b. Gages checked by calibrated gage or replaced? �Yes ONo /A ? Q„ � ((�„ �� � p,uC � a�
c. Pressure reducing valves passed full flow test? ❑Yes ONo /A _ , ,
v► � � iJ � �. � .
C. Maintenance
1. Regular Maintenance Items
a. If any sprinkler failed the sampling testing of
Parts II.B.3.c, d, e or f of this form, were all sprinklers _
represented by that sample replaced? ❑ Yes a NoJ�N/A � "�
b. If sprinkler have been replaced, were they iJ
proper replacements? ❑ Yes O No'� N/A �� n � — C"�'��`' G. L� r�r ./ 3 0 �
c. Used hose was cleaned, drained and dried
before being placed back in service? ❑ Yes O No $�N/A
d. Hose exposed to hazazdous materials was disposed
of or decontaminated in an approved manner? 4Yes ❑No'� N/A
e. 5ystems normally filled with fresh water were drained and '
refilled twice if raw water got into the system? OYes allo�i/A Part IV — Inspector's Information
f. If any of the following were discovered, was GENERAL SPRINKLER CORP.
an obstruction investigation conducted? ❑ Yes O No�N/A Inspector:�Ri�r3A0a NA0�1'� Compan�
Explain reasons(s) and obstruction investigation findings in Part III �{(� B�►R LAKE, MN 55110
l. Defective intake screen on pump supplied from open sources Company Address:
2. Obstructive material discharged during flow tests I staxe that the information on tkus form is correct at the time and
3. Foreign material in dry-pipe valves, check valves or pumps place of my inspection, and that all equipment tested at this time
4. Foreign material in water during drain test or plugging of was left in operating condition upon completion of this inspection
inspector's test connection except as noted in Part IIi abov .
5. Plugging of pipe or sprinklers found during activation or work
6. Failure to flush yard piping or surrounding mains following Signature of Inspector: A ate: �'( �� tZ
� new installation or repairs
7. Recor� of broken m�i�s in the v Li or Certifi Number (if applicable): � 7� �_
42009 National Fire Sprinkl�t' Association, 40 Jon Barrett Road, Patterson, NY 12563 (84� 878-4200 Form 25-13W-08 Sheet 2 of 2
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SPRiNKLEB � n v
C�3RPORATI(�3N CONTRACTORS FOR ALL TYPES OF F/RE SUPPRESS/ON SYSTEMS
MN Lic. # C002 TRIP TRIP
W I Lic. # 222173 INITIAL POINT TIME
ia Lic # FP-046 ZONE # TAMPER ' ALARM STATIC RESIpUA AIR PSI PSI SEC. REMARKS
❑ Main Office:
1863 Buerkie Rd. Z�N� #1
White Bear Lake
MN 55110 �� � �� � O
(651) 484-5903 � y ( � � `/ d � . � ��N�
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(651) 484-9514 (fl , ,
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494 184"' Street
Osceola ` � ; �
W I 54020 { IJ�j ��+,,
(715) 294-4387 ��� 0 �, �' �� � �/
(800) s�e-s��� ZONE #4 ,1� Z.� GC 0�- ��� VM,S
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