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PGS.
FIRE-GUARD
SPRINKLER SERVICE, INC,
INSPECTION
CONTRACT NO.
PG. OF
INSPECTION
REPORT NO.
MN LICENSE NO:
COOO18
BUREAU
FILE NO.
CONFlfIMEl}
WITH
2055 WhIte Beer Ave. No" sune C
St. Paul. Minnesota 55109
Pti:651-748-9499 . FAX:651-748-9143
erN, STATE, ZIP;
CITY, STATE, ~
,
REPORT TO:
BLDG. NAME:
STREET:
ADORESS:
TECHNICIAN:
LICENSE NO.
DATE:
I a I j.,8lrJ!L
/ I
OWNER'S SECTION (To be answered by owner or occupant)
A. Explain any occupancy hazard changes since the previous inspection.
B. Describe fire protection modifications made since last inspection.
C. Describe any fires since last inspection.
,. ,~
D. Whenwas the system piping lesl ch80ked lor stoppage. ~ or Wmal~ JI. 1 'J"n ",X III . .
E. When was the dry.piping system last checked for proPSr p~~ i T",,- td-n rl
F. Are dry valves adequately protected from freezing?
/
, . yes n.8. no yes n.a. no
INSPECTOR'S SECTION (All responses reference current InspectIon) c. Has the operation of the air or nitrogen supply been tested? l(
1. GENERAL Is it In service? ,.....................................................................................
..Islhe building occupied? .................................................................... X d. Were low poinls drelned during Ihlsinspecllon7 ................................. D(
b. Are all systems in service? .....................................".......................... V e. Did qulck-openlng devices operate satisfactorily? ..........................,.... X
c. Is there a minimum of 18 in. (457 mm) clearance between the top )(' f. Old the dry valve trip properly during the trip pressure test? ............... y
of Ihestorage and the Qprinklerdeflector? ................,;...................... : ;g. ~id ,t~ h~atl~~ lit9.U,IPrt:l,e~t I':'~I~ dry-pipe valve room operate '/.
d; In areas protected by wet system. does the building appear 10 be at the'time of inspection? .....................................................................
properly heated in all-areas, 'including blind attics' and,perimeter .
areas, were accessibte? Do all exterior openings appear to be )( 7, SPECIAL SYSTEMS (See Hem 16) ,
e. 6:~~: ~:n~~:ec::'::~~~~k,~;~~~;;~.~t.j;~~;~ii~i~.~;;y~:::: a. Old,the deluge ()fpre-action valves operate properly during lestlng?.. ~ -/. -I
V b. old the h8at-resPo:ni1v8 devices operate properly during testing? ...... V I
I... c. Did the supervisory devices operate during testing?.......................... /\.
a. CONTROL VALVES (See item 14) ,
a. Are all sprtnk~r system control valves all all other valves in the X. a. ALARMS V
appropriate open or closed position?................................................ a. Old water motor and gong test satisfactorily? ............"........................
b. Are all cohtrolll8lves In the open position and locked, sealed or X ,. b. Old electric alann ,..I satisfactorily? ................................................... X
equipped with a tamper swttch? .....................................,................... c. Old supervisory alarm service test satisfactorily? .........................,..... y
~"
3. WATER SUPPLIES (See Item 15) ><' 9. SPRINKLERS 11
a. Was a water now test of main drain made at the sprinkler riser? ....... 8. Are an sprinklers free from corrosion, loading or obstruction to spray
d1sch_? ........................................................................................... II \l!'.<
4. TANKS, PUMPS, FIRE DEPARTMENT CDNNECnDNS b. Are sprinklers over SO years old, thus requiring sample testing? ........ ~~.~,~" y
a. Are fire pumps, gravity tanks. reservoirs and pressure tanks In ')( c. Is stock of spare sprinklers avaHable? ................................................. 'Y "."";~~'
good condition and properly maintained? ......................................... d. Does the Interior condition of sprinkler system appear to be X
b. Are fire department connections In satisfactory condition, satisfactory? ..........................................,....................,.................".....
couplings free. caps In place, and check velves tight? Are y
they aCC8881ble and visible? .............................................................. 10. Date dry-pipe valve trip tested (control valve fJ..rtlaU9pen)
;;.: (..e trip lesl which loIIowsl.....................lo' ..:7.,,'iI. ..!lH..............
5. WET SYSTEMS (See Hem 13)
.. Are cold weather valves (0.5.& Y.) In the appropriate open X "'. 11. Date dry-pipe valve trip tested (control valve fully op;!.p)
or closed position? .......,............................................,........................ (s.. trip test which loIIows) ........................M....:J...lm'A!,(.... - -- -
b. Have antifreeze systems solutions been tested? .............."......,......... 1i '()ate'quICk-opening devl'ce tested (~ee:>ASCOAtrip lesneport) ,';......: V .~
c. 'Were the antifreeze test results satisfactory? .................................... >",.-,--1"""". '.,:. _,' 'C__;.,,'.':!:.'_': .
, y 13: '.:(.-"j '.;'.......,f. .:":,., ," ",'. ' '",L
6. DRY SYSTEMS (See'ltems 10 to'1'48Ddanecb8d.report),..,~;~,_" Date d8luge or p'reactlon VQlve'tested ................................................:
a. Is the dry valve in service? , ,
: ~ ':. '.. ' ,..: - ',' : , ' . , \L
b. Are the air pressure and priming water level In accordance . 'I 14. See; ~korY8iv8 M.~lntenance Table.
with the manufacturer's instructions? .....".......~............................""..
CDNTROL MAI~ANCETABLE
'a.
'r
Closed Signs
- ""'-4'
- (_A
ATEll'TLOW
Explain Abnormal Condition
Control Valves
System Control Valves
Other Control Valves
}-1
Number
t'rJ-H- ,
I
I
Type Open
..oK
"~.P.
p,'I/ ~
Row
- PreSSUre
Secured
'J:;-
Test Pipe
L'Jl'l!led
Size-
o Test Pipe - ,-
-+'-
~
Pressure
BefOi"e--
Pressure
After
Test Pipe Size Pressure Flow Pressure
. . located - .. .Test Pjp~.. I, _.,.Before... Pressure After
f I
Condition: .
Model:
LocatIon? Test Result?
\A,..
/1 I
/0....
1 I 1
18. Type of Equipment
Manufacturer:
Auxiliary Equipment: No?
'A I;'
rlJ
)(lV
/'
Type?
17. explain any -No" answers and comments:
A'/'#uz.-
18. Adjustments or corrections made during this Inspection:
19. Although these comments are not the result of an engineering review. the following desirable Improvements are recommended:
tt~1\f'
WHITE: CLIENT
YELLOW: OFFICE
PINK: INSURANCE AUTHORITY
/
FIRE-GUARD
SPRINKLER SERVICE, INC;
2055 White Bear Ave. No., Suite C
SI. Paul, Minnesote 55109
PH: 651-748-9499 . FAX: 651-748-9143
MN License No. COO018
DRY PIPE VALVE TEST
Bus. c".J./ DATE: In/A. B / a '1
()r 1) e ISO FILE NO.
DRY PIPE VALES
NO.1 NO.2
NO.3
SIZE, MAKE, MODEL & YEAR ;;), 'f-- CeI1 frd
OF MANUFACTURER
CONTROL SPRINKLERS IN )1e "2 "t.
PRESSURE (LB.) AIR 5~-
BEFORE TESTS WATER /00
CONTROL VALVE WIDE OPEN? t3v+f <f' 'f Iv)
(IF NOT, HOW MANY TURNS?) S- Ij-vf' (J 9
OPERATED AT: ,
AIR PRESSURE (LB.) I 5' ,pSI
TIME (MIN., SEC.) - ~
OPERATION INDICATE: SAT
(SATISFACTORY, PARTLY
SATISFACTORY, OR FAILED)
REASON FOR FAILURE OR
PARTLY SATISFACTORY
VALVE RESET DRY? Yy~
LIST REPAIRS MADE /
CONDITION: ('" J
INTERIOR OF BODY (
WATER FROM TEST PIPE
MOVING PARTS
SEALS
RUBBER FACING 0/
ALARMS OPERATED? '\1 C9,
/, 'It'
./'
~AKE,MK)OEL,YEAR
/' Q.PERATION INDICATE:
SATlSFACT Y, ILED OR SHUT OFF
ER OR lEASEE OF THE PROPERTY)
ES
WHITE: CUENT YELLOW: OFFICE PINK: INSURANCE AUTH()Al1Y