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Kitchen Hood Fire System Inspection & Maintenance Report
Northland
Fire &
Your Life Safety Specialists
4445 w, 77th Sl., Su~. 125, MinneepoUs, MN 55435 (952) 893,0905
DATE OF SEFlVlCE P.M,
~5
ANNUAL SO.4I-ANNUAL. INSTALLATION
X
LOCATION OF SYSTEM CYLINDERS
IL. , Ie iN y\
MANUFACTURER MODEL NUMBER WET DRY CHEMICAL
An~L< I IZ-/Oz.. X
CYUNDER SIZE,'f'STER CYLlNDERplZE SLAVE CYLINDER SIZE SLAVE
..:3 ,,/10'-' .3. Jlon
FUSE LINKS 3600 F
FUSE LINKS 4500 F
FUSE LINKS 5000 F
OTHER
Name ~:: t(~:Z:~l: ~ 13
Address ~;.; , ~
/
FUEL SHUT-OFF
ELECTRIC
GAS
/YIP<'"~
SIZE
I ~5
<5
City ?nor [01<" "",,,,I ~~:P...2..
,
Teleph~ne ('95.)) ~.;(J7- Wctb8store No.
.,
Owner 0' Manager nO. v ~ eGo rlso ,..,
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COOKING APPUANCE LOCATIONS & SIZES: LEFT TO RIGHT
'-'y'Y 1'-'1'" ~ b;.~ ""'oI~"",o,~t
~~~ ~~~
1. System interlocked with building fire alarm 0 0 Jill 20, Check travel of cable nuts! 5-hooks 0 0 JZJ
~: ~~~v~~conctDozzJElS, - ,,', .~g~';~}~=~~~~'1flame-,-.,,-,..~-gg.,
4. System installed per U.L 300 standard & meets 23, Proper clearance-flame to fi~ers J!! 0 0
manufacturers U.L listing & N,F.PA standards ~ 0 0 24, Exhaust fan in operating order ~ 0 0
5. Hood/duct penetrations sealed w~h weld or UL device t7' 0 0 25, All fi~ers replaced % 0 0
6. Check if seals intact, evidence of tampering ~ 0 0 26, Fuel shut-off in on position ji! 0 0
7. if system has been discharged, report same 0 ~ 0 27, Manual & remote set/seaIs in place 13 0 0
8. Pressure gauge in proper range (~ gauged) 0 0 J!J 28, Replace systems covers j1J 0 0
g, Check cartridge weight (~ applicable) 13 0 0 29, System operational & seals in place j!J 0 0
10. Dry system 6 year maintenance date! wet system 12 30, Slave system operational P' 0 0
year hydro-test date ~ 0 0 31, Clean cylinder & mount 21. 0 0
11. Inspect cylinder and mount ~O 0 32, Fan waming sign on hood if 0 0
12. Operate system from terminal link J:;;l 0 q 33, i>roPEl[signage and Jl8I'SOI1nel instructed in manual
13. Test fOIHll'Oper operation from remote PI. 0 0 CiPerB!ion of system pOD
14, Check operation of micro switch "if 0 0 34, Proper hand portable extinguishers :c:r 0 0
15. Check operation of gas valve J1f 0 0 35, K class fire extinguisher in cooking area % 0 0
16. Clean nozzles ~ 0 0 36, Portable extinguishers properly serviced J3 0 0
17. Proper nozzle covers in place PI. 0 0 37, Service & Certification tag on system ;a 0 0
18. Check fuse links and clean ?f 9- 0 38, Safety chains on all gas appliances attached and secured 0 0 if
19, Replaced fuse links 0 Y' 0 NOTE DISCREPANCIES OR DEFICINCIES BELOW 0 0 0
COMMENTS:
SERIAL NUMBER
LAST HYDRO reST DATE
bltST RECHARGE DATE
f2~5114e3
00
MANUFACTURER'S MANUAL RefERENCE
NOT~ NON COMPLIANT SYSTEMS MAY FAIL TO EXTINGUISH/ 8UPPRIU It F..I..
On this date, the above system was tested and inspected in accordance with procedures of the presently adopted editions of
NFPA 17, 17 96 manufacturer's manual and was operated according to these procedures with results indicated abov
-'''\.-
x
SERVICE TECHNICIAN PERMIT NO, DATE: TIME: AM PM ctUSTOMERS AUTHORIZED AGENT
The above service technician certifies that the system was personally inspected and found conditions to be as indicated on this report.
WHITE - CUSTOMER
.
YELLOW - DISTRIBUTOR
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PINK - AUTHORITY HAVING JURISDICTION