HomeMy WebLinkAboutWet Pipe Fire Sprinkler System Inspection Report � �z�a-t3
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Form for Inspection, Testing and Maintenance of MO�{� QNFS'a
Wet Pipe Fire 5prinl�ler Systems L/U lh ny�pWep/yyFlro3pinlCerintlustry
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 J� Annual ❑ Third Year ❑ Fifth Year
Owner: ��_TQ.+�I�,S.'��C, Owner's Phane Number: Q S Z �����
Owner's Address:�1Q� L`TL� �� �d�l- NW � t � D
Property Being Evaluated: 1w� � [�1LS► m�'��L�c �J�CI�L
Property Address: � 1� �en � p6� PlT Q.� � T-P�1� �.A1�.� �:�77 /'�--
Date of Work: �--10�\2. 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 Part III of this form.
2) Inspection, 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,
with downstceam pressure per design criteria, and in good
B. Has the occupancy and hazazd of contents condition with handwheels not broken? ❑ Yes ❑ No�N/A
remained the same since the last inspection? Yes ❑ No
� d. Hydraulic nameplate (calculated systems)
C.Are all fire protection systems in service? � Yes ❑ No securety attached to riser and legible? ❑ Yes ONo ❑ N/A
D.Has the system remained in serv�ce without 4. Annual Iuspection Items (in addition to above items)
modification sin�e the last inspection? t�] Yes ❑ No a. Proper number and type of spare sprinklers`?�1 Yes ❑ No ❑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)? �OYes ONo ❑ N/A
F. Name and address of property insurance contact: 2. Free of corrosion and physical damage? ❑ Yes O No ❑ N/A .�
G. Polic number if known : 3. Proper clearance below sprinklers? ❑ Yes ❑ No ❑ N/A
y � � 4. Free of foreign materials including paint? ❑ Yes ❑ No ❑ N/A
Y_�Gc ,_�.L 5. Liquid in all glass bulb sprinklers? ❑ Yes ❑ No ❑ N/A
r or R entative rint n e) Signature and Date c. Visible pipe: 7
1. In good condition/no external corrosion. �il Yes ❑ No 0 N/A
PaYt II — InspeCtor'S SeCtion 2. No mechanical damage or leaks7 Yes ❑ No ❑ N/A
A. InspeCtions 3. No external loads? � Yes 0 No 0 N/A
1. Daily and Weekly Items d. Visible pipe hangers and seismic braces
a. Control valves supervised with seals passed in pection not damaged or loose? � Yes 0 No ❑ N/A
in accordance with ILA.2.a below? �Yes 0 No ❑ N/A e. Hose, hose couplings and nozzles on sprinkler
b. Backflow preventers: system passed inspection per NFPA 1962? ❑ Yes O No`j� N/A
1. Accessible and isolation valves open? ❑ Yes ❑ No N/A f. Adequate heat in areas with wetpiptng? �] Yes O No 0 N/A
2. Sealed, locked or supervised? ❑ Yes O No N/A g. Internal inspection of the pipe performed in the
3. Relief port on RPZ not discharging? ❑ Yes ❑ No N/A last 5 years (remove a flushing connection and
2. Monthly Inspection Items (in addition to above items) one sprinkler near the end of a branch line)? 0 Yes� No �❑ N/A
a. Control valves and valves on backflow (If `7Vo ", conduct internal inspection)
preventers with locks or electrical supervision: 5. Fifth Year Inspection Items (in addition to above items)
1. In correct (open or closed) position? � Yes ❑ No ❑ N/A a. Alarm valves and associated strainers, filters and
2. T,ock or supervision in place7 '�1 Yes ❑ No ❑ N/A restricted orifices passed internal inspection?0 Yes a No j�l N/A
3. Accessible and free from external leaks? �1 Yes ❑ No ❑ N/A b. Check valves internally inspected, all parts
4. Provided with appropriate wrenches? � Yes �] No ❑ N/A operate properly and are in good condition? ❑ Yes J� No a N/A
5. Provided with appropriate identification? �(] Yes ❑ No ❑ N/A c. Internat pipe inspection performed per 4.g? ❑ Yes � No ❑ N/A
b. Sprinkler wrench with spare sprinklers? � Yes a No 0 N/A B. Testing
c. Gages on systetn in good condition and Report any failures on Part I77 of this form.
showing normal water supply pressure? � Yes ❑ No ❑ N/A 1. Quarterly Tests
d. Alarm valve free from physical damage, trim a. Mechanical waterflow alarm devices passed .
in correct (open or closed) position and no tests by opening the inspector's test connection
leakage from retarding chamber or drains? ❑ Yes O No�bi N/A � alanns actuating and flow observed? y�Yes ❑ No ❑ N/A
3. Quarterly Inspection Items (in addition to above items) b. Post indicating valves opened until spring or torsion
a. Fire department connections visible, accessible, fek in the rod then closed back'/a tum? a Yes 0 No�N/A
couplings and swivels not damaged, gaskets in c. Main drain test for system downstreaxn of backflow device or
place and in good condition, identification sign(s) pressure reducing valve:
in place, check valve is not leaking, clapper in place
and operating properly and automatic drain valve r. Record statie pressure � 1 psi, residua pressure � psi
in place and operating properly? }� Yes 0 No ❑ N/A 2 Was flow observed? Yes ❑No ❑ N/A
(If plugs or caps are not in place, inspect interior or obstructions) 3. Are results comparable to previous tests? Yes a No O N/A
b. Alarm devices free from physical damage? �Yes �7 No ❑�1A
�02009 National Fire Sprinkler Association, 40 Jon Barrett R�ad, Patterson, NY 12563 (845) 878-4200 Form 25-13W-08 Sheet l of 2'
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2. Semiannual Tests (in additioo-to previous items) 8. Abnormally frequent false-tripping of dry-pipe valves
a. Valv� supervisory switches indicate 9. System is rehuned to service after an extended period of time
movement? �'Yes O No O N/A out of service (more than one year)
b. Electrical waterflow alarm 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 flwces in copper pipe
with alanns actuating and flow observed? � Yes 0 No � N/A g. If conditions were found that required
3. Annual Tests (in addition to previous items) flushing, was flushing of system conducted? f.] Yes 0 No�N/A
a. Main drain test for systems not tested qu rly: h. Was a drain test conducted after opening any
� r'� „�� .����rri� _/ closed valves? ❑ Yes ❑ No� N/A
1. Record Static�-psi and Residual Pr ssure �psi i. Adjusted, repaired, reconditioned or replaced components
2. Was flow observed? Yes O No ❑ N/A had the associated tests and/or inspections required
3. Are results comparable to previous tests? Yes O No ❑ N/A by Table 5.5.1 of NFPA 25 performed? ❑ Yes O No� N/A
b. Are all sprinklers dated 1920 or later? Yes 0 No 0 N/A 2. Annual Maintenance Items (in addition to previous items)
c. Sprinklers with fast response elements 20 years a. Operating stem of a11 OS&Y valves
old or more replaced or successfully sample lubricated, completely closed, and reopened? �Yes O No 0 N/A
tested in last 10 years? ❑ Yes 0 No� N/A b. Sprinklers subject to recall repiaced? ❑ Yes ❑ No� N/A
d. Standard response sprinklers 50 years old or more replaced or c. Sprinklers and spray nozzles pmtecting
successfully sample tested in last 10 years? ❑ Yes 0 No� N/A commercial cooking equipment and ventilating
e. Standard response sprinklers 75 years old ormore replaced or systems replaced except for butb-type wluch
successfully sample tested in last 5 years? ❑ Yes 0 No� N/A show no signs of grease build-up? ❑ Yes ❑ No+� N/A .
f. Dry-type sprinklers replaced or successfully
sample tested in Iast 10 years? ❑ Yes O No ❑ N/A Part III - COmmeuts (Any `'1Vo " answers, test failures or other
g. Antifreeze solution specific gravity: problems found with the sprinkler system must be explained here.
1. Cotrect at mos°fremote 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? G7 Yes d No N/A subject of a recall or replacement program.)
3. Correct at other test points (over 150 gal)? ❑Yes O No N/A
h. All control valves operated through full range � � � G
and returned to normal posirion? � Yes 0 No O N/A �� i k����, � � �� t D � •
i. Bacl�low devices passed bacl�low test? ❑ Yes �] No N/A �
j. Bacl�low devices passed forward flow test? ❑ Yes O No N/A
k. Pressure reducing valves passed partiai flow? ❑'Yes O No N/A
4. Test for every third year (in addition to previous items)
Hose more than 5 years old connected to the system 2 �, a� L��j �{ C�`� W A t 12-
has been service tested per NFPA 1962. Water � .
discharged and water flow alarms operated? ❑ Yes O No� N/A � ►`1 ri f`t �
5. Tests for every fdth year (in addition to appropriate items) { � /' �,rD
a. Sprinklers above high temperature tested? ❑ Yes a No� N/A L� i� �- �J �Y ��/+Pc I J°C ���{ �� �
b. Gages checked by calibrated gage or rep lac e d? O Yes T� No ❑ N/A
c. Pressure reducing valves passed full flow test? ❑I'es �To �i/A _ �
3 � ob � ,�
C. Maintenance
�- 1 V�SDZe-�i � i `� l�ti� , � —oa�� �.G��.6oC,
s 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 ❑ No � N/A �"► � -
b. If sprinkler have been replaced, were they
proper replacements? ❑ Yes 0 No f�i N/A
c. Used hose was cleaned, drained and dried
before being placed back in service? ❑ Yes ❑ No7� N/A
d. Hose exposed to hazardous materiais was disposed
of or decontaminated in an approved manner? ❑Yes ❑No}� N/A
e. Systems normally filled with fresh water were drained and
refilled twice if raw water gotinto the system? ❑Yes allo Parf IV - Inspector's Information
f. If any of the following were discovered, was $pR1NKLER CORP
an obstruction investigation conducted? ❑ Yes 0 No�l N/A Inspector tMOe�'j0► Co�n���L
Explain reasons(s) and obstruction irrvestigation findings in Part III �
1. Defective intake screen on pump supplied from open sources company Aaaress: WHITE BEAR I.AKE MN . 55110
2. Obstructive material discharged during flow tests I state that the information on this form is conect 1t the time and
3. Foreign material in dry-pipe valves, check valves or pumps place of my inspection, and that all equipment tested at ttus time
4. Foreign material in water during drain test dr plugging of was left in operating condition upon completion of tlus inspection
inspector's test connection except as noted in Part III above.
5. Plugging of pipe or sprinklers found during activation or work " $� `0,12
6. Failure to flush yazd piping or surrounding mains following Signature o€,Inspector: Date:
new installation or repairs `
7. Record of broken mains in the v License or Certification Numbe {i app li c a b le): ���
�2009 National FSre Sprinkler Assceiation, 40 Jon Barrett Road, Patterson, NY 12563 (845) 878-4200 Form 25-13W-08 Sheet 2 of 2
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CURP+C�BATIQN CONTRACTORS FOR ALL TYPES OF F/RE SUPPRESSION SYSTEMS
MN Lic. # C002 TRIP TRIP
WI Lic. # 222173 ``" INITIAL POINT TIME
. ia Lic # FP-046 ZON� # TAMPER ALARM STATIC RESIDUA AIR PSI PSI SEC. REMARKS
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❑ Main Office: �,J � �f � n � ��( � �/
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(651) 484-9514 (f)
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❑ Wisc. Office: ZONE #3 ��� � � � �
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