HomeMy WebLinkAboutFire Inspection Report
..~SPECTION REPORT
NO..
CONFERRED WITH
'WE.':S
REf'ORTtO~E--3t-J \;~~<:: ..-
~Incl:i l. .cl\~ '~,...-:. ,'- .
ClTV&STIlTE ..e.a4f\ka'. .. ....\ -
I -
ATT
~
t~"~"IEAAL .
A;: (To be ._ by tha Owner or Qwne(s rapresantatlY9)
a. Have there.been any changes in the occupancy classification, machinery or operation$since the last inspection?
b. l-taVe there been any changes or repairs to the fire protection systems sinQe the last irtapeCtion? ..
c. If a fire has occurred. $inti! the last inspeCtion, have aU damaged sprinkler system components been replaced?
d. HaS the piping In all dry systems been checked for proper pitch within the past five years?
Data laSt chacked
e. Has the piping in all systemsbeench~ fOr obstructive materials?
Data laat _ (chacklng is racommanded .flaaat .vary 5yaars)
f. Have aU fire pumps been 1Hted to their tuft capectty.th~ the,U~.t1f,hose,~ or now in8terswlthin the PBSt ,12 'monb?
g. Are gravity, surface or preSsure tanks piotected from freezing?
h. Are any of the sprinklers 50 years old or older? (testing and/or replacement is rt.~... .. '".... _ for such sprinklers)
1. Are any extra high temperature solder sprinklers regularly exposed to", 'f'._~,~Jres near 300"F?
B. (To be answered by the inspector)
a. Have the sp'rinkler systems been extendtd to- all visible areas of the buHding?
b. Does there appear to be proper clearanoe between the lop of aU storage and the sprinkler deflector?
c. Are the building areas protected by a wet system; heated, including. Its blind attics and perimeter areas, where accessible?
d. Are all visible exterior ooeninos_,~:-,-..-,-": aoainst the entrance 01 cold air?
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GRINNELL ., .'PHONENO.~
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Vaa I N.M I No'
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BUREAU ALE ____
N~Li::'> ,
REPORT OF INSPECTION
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'''hacklng is recommended at least every 5 veers)
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Ves
No
Signs
Yes No
Valve
Open
Yes No
Secured?
lSaaied?)
ff yas. how? Locked?)
Yes No Supvct?\
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I
Supervision
Operational
Yes No
2. "';0
J._""",_ VALVES
a. Atei all sprinkler system main control valves and all other valves in the appropriate.open or closed position?
b. Are all control valves sealed or supervised In the open position?
Control
Valves
No.
of
Valves
Type
Easily
AccasslbIa
CITY CONNECTION
TANK
""""'t).l>t't" R~"'\
SECT10NAL_
SYSTEM ~KY I
ALARM LINE
3. WATER SUPPLIES
a. Water supply source?
Waterflow Teat Results Made During This Inspection
Test Size Static
Pipa,TasI ~_
located "ff.9 _'$fore
~l'<.,-<-r:4.! -e;" ID
I
ci.,Pfl.\oR LAkE
Gravity Tank
W-A
Pressure Fire Pump & Tan!'
Pressure Fire Pump & City
Pressure Fire Pump & Ponrl
~....~'(lt -
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KFV
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Flow
presSure
~
Static
P-
After '
OS,""
Tast
Pipa,
Location
Siz.
Taat
PiDe
Static
Pr8S$ure
Before
Row
Pressure
Static
_re
After
4. TANKS, PUMPS, FIRE DEPT. CONNECTfONS
a. Do fire pumps, gravity, surface or pressure tanks appearlO be in good external condition?
b. Are gravity, surface and pressure tanks at the proper pressure and/or water levels?
c. Are fire dept. connections in satisfactory condition, couplings free, caps or plugs in place and check valves tight?
d. Are fire dept. connections visible and accessibl~?
5. WET SYSTEMS (c"', A
a. No. of systems- Make & Model 1"'- - \
b. Are cold weather valves in the appropriate open or closed position?
If closed, has piping been drained?_
c. Has the owner or owner's representativEl been advised that cold weather valves are not recommended by NFPA?
d. Have all the antifreeze systems been tested?
e. Date antifreeze systems were tested
f. The antifreeze tests Indicate protection tn'
system 1 ? .<:1 4 .c; temperature
g. Did alann valves, waterflow alarm indicators and retards test satisfactorily?
Ves I N.^-i No*
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SG4550-A2-1
INSURANCE BUREAU COPY
:t:Not Applicable
'Explain (No) Answers on BElck of Sheet 2 ~
..../Fire&. 1 ..... ... ..... .
S8curit.'l.'!Jj,l*,rf",;j~!~f~":f ''3. }6 ~oS
REPORT OF INSPECTION
~t!.";''''''''\NT _ . BL~~
..8.~..~. 1 .1
~<f<Q.",....< I 14it}~~ ~~~):).(.
'D8l8l8sttril>tested .... ~
b. Is the air pr88Stlreand prirhhp w~ter levels normal?
c. Old the ak'oompreSsOf operatesatlsfactorily"
d. Were an lOW points drained duringthisJnspection"
e. Did all quick opening devices operatesatistactorl~:')
f. Did all the dry valves operaW'i88tisfactorily during, this inspectIOn?
-g. 00 dry valves appear to be Protected from freezing?
h. Is the dry valve house ~o)
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BUREAU'FILE
NO......_
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INSPECTIOIllfU;PORT
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7. SPECIAL SYSTEMS /')
a. No. of systems (j
Tyro
b. Were valves tested as required?
c. Did altheat f8$pbflsMI:.Systerns'6pSrate'satfsfactorily?
d.. 'OIdJhe S'4"l"'i""'Y~ /ll!8rat41du"'jO 1Ostilg7' 'c
Heat ResponsIVe, Devices: Type Type of test
ValveNn 1~.....2. ..3......4... .5. ..6... ValvaNo
ValveN'" 1......2. ..3......4.. .5......6.... ValvaNo,
Valve N" 1"... .:L.... .3..... .4..... .5..... .6... Valve No,
Valve N.... 1. . .. . .2. .. . .. 3. . . .. .4. . . .. .5. .. . . .6.. . Valve No,
Auxlllary. equipment: No. I ') Type t-... \ ~
locatlor
Test reSulf~
Make & Model
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.
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......2......3 ....4......5......6...
...2......3......4. ...5......6..
....2......3......4......5......6......
~..2......3......4......5......6.
8. ALARMS
a. Did the water motors and gong operate during testin~?
b. Did thee/ectric alams operate durfng_ testing?
c.Did the Bl,lpervisory alarms~rate during testing?
. 9.SPRlNKLERS. PIPING . .
a. ~po,~~ktersganemJiyappear to; be:in good'~enl81 coridition"
b,., Do-~iRtdefs-~'~rto'be free' 01 corrosion, paint, or loading and visible obstructions?
c. AI'eJ extra sprlnlders available on the premises?
d.DOes the exterior condition-~f piping, drain valves, check valves, hangers, pressure gauges, open sprinklers
and strainers appear to be'satisfactory?
e. Does the hand hose on the sprinkler system appear to be in satisfactory condition?
10. EXPLANATION""OF "NO" ANSWERS (For Sections 18 thru 9):
Yes N.AJ: No.
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~ 11~ THE; lN~~~.~~-~t:~()~~fE~RY tPRO~~~EN~S~.~.O~VER: THESe! S~.~E~TI~~ A~E NC?T ~~U~!_t.A~ ~INEEFUNG SURVEY:
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-'VI."'r-'LI:..I"}\::.N \ ,...1-
'12. AItJUSTMENTS OR CORRECTIONS MADE:
10Q1'.)t...
.,
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13. UST CHANGES IN T~ OCCUl>ANCY HAZARD OR FIRE PROTECTION EQUIPMENT, AS ADVISED BY THE OWNER IN SECTION IA:
,.,. <;> 1\1 t"_
14. INSPECTION AND SUGGESTEDIMPROVEMENTSi\.., bSS1!Il-Wt.1fTHE UNDERSIGNED OWNER OR OWNEII'.$.RE"rH~NUJIllE?
SiQnature of owner or owner's representativeY ~ I i. ~1~~ Date -<.. - " ~
DUPUCA TE Tn,.
STREET
CITY & STATE
ATT.
SG4550R1-2
,
:;:IP
;NotApplicable
'Explain (No) Answers on Back of Sheet
INSURANCE BUREAU COpy
1:qeO/Fire ~ / SimplexGri""."
SecurIty
DRY PIPE VALVE TRIP TEST REPORT
FOR J::h't' ~) ~ I 1'\", ~ ~ R..} ~\c; - INSPECTION NO.
STREETP.lQ9'* 1./. ~ -PK\..JY ~=cl~;oR Ln....~ STAT M lI.'_CONTRACTNO.
DATE OF TRIP TEST - )0 ~ 6~ - INSPECTOR. ~ DAY WORK NO.
NOTE: BEFORE ANY DRY PIPE VALVE IS TRIP TESTeD. THE WATER SUPPLY LINE IT SHOULD B W.9..~ql,!tit'LY FWSHEO THE 1\YO INCH DRAIN BELOW
THE VALVE SHOULD BE OPENED WIDE, AND WATER AT FULL PRESSURE HOULO BE 01 I-tAHGkO LONG ENOUGH TO CLEAR TI-le PIPE OF ANY
ACCUMULATION OF SCALE OR FOREIGN MATERIAL. IF THEAE IS A HYDRANT ON THE SUPPLY LINE, THIS HYDRANT SHOULD BE FWSHED BEFORE
THE TWO INCH DRAIN IS OPENEO; THE DRIP VALVE ON THE DAY PIPE VALVE SHOULD BE CHeCKED BEFORE TRIPPING THE DRY PIPEVALVEiE. TO see
THAT IT IS IN OPERATING CONDITION.
DRY PIPE VALV~ -~I. SYOSTry:'~ )' SYSTEM NO. ( ) j SYS,-,iMNo.(
VALVE SERIAL NUMBER _,
~E~~~j I
I Ac.=.1
I.!,J INCH I INCHI
I E~\"l ~~ I
. (APPROX) I
I'~o-(,)t./ I
1~~~PI.J'
PRESSURE BEFORE TEST I \ .. ... LBS
::TER I ~ ~ LBS
SIZE ANO LOCATION OF TEST VALVE I.lo}". \/
WAS GATE VALVE BELOW DAY VALVE OPEN W$De AT TEST? r . ~-
(tF NOT. HOW MANY TURNS?) .
I AJR PRESSURE
'VALVE TRIPPED AT WATER PRESSUREI 4 TJ
I TIME I MIN~\
IF SYSTEM FLOODED, LIST TIME WATER I
REACHED TEST OPEN1NO MIN' --
I
MANUFACTURER eNAME)
VALVE MODEL
. VALVE SIZE
CONTROLLING SPRINKLERS
I (LOCATION)
I (NUMBER)
DATE LAST TRIP TESTED?
DATE LAST OPERATED?
PERFORMANCE
I INTERIOR OF ,BODyl
I MOVING PARTS I
RUBBER FACING I
I SEATS
RESET?
OK> AlARMS OPERATE AT TRIP TEST?
VALVE CONOiTION
ALL LOW POINT DRAINS BLOWN OUT?
WATER CONTROL VI4J..Ye LEFT
opeN AND SeALED?
ALARM CONTROL VALve LEFT
OPEN AND SEALED~_
QUICK OPENING DEVICES
DEVIOE SERIAL NUMBER
MANUFACTURER (NAME)
TYPE AND MODEL
AIR PRESSURE IN UPPER CHAMBER
QUICK OPENING DEVICE TRIPPEO AT'
PERFORMANCE
QUICK oPENING'DEVICE LEFT IN SERVice
AND CONTROL OPEN AND SEALED? '
UST ANY. UNSATISFA............-., CONDITIONS:
REMARKS ~ PFR
~bU.J:\li:.. .
SYSTEM NO. (~p, )
/1
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SEe LeS
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AA 4::>>74 R:>
SYSTEM NO. (
INCH
'INCH
(APPROX)
(APPROX)
(APPROX)
LBS
LBS
LBS
LBS
CBS
LBS
Lasl LBS LBS LBS
LBSI LBsl LBS LBS
SEcl MIN SEcl MIN SEC MIN SEC
SEcl MIN SEcl MIN SEC MIN SEC
I I
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I
I
SYSTEM NO. (
SYSTEM NO. (
SYSTEM NO. (
SEC
1
:1
J
LBS
LBS
LBS
SEC
SEC
LBS
Ca..N.E)_
AlARM _ ~~
~.
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/
INSPECTION REPORT
NO. .................
CONFERRED WITH ""1i-.~UPP.LEMENTAL RECORD OF INSPECTION
..\f:J.~'S......................~.'..L~ 1'v\1'l.\~ I BL~<:;;.
1:QCD!Fire ~ /SimPlexGri""ell
Security :s- )0 -05'
~~~~~~~~~.
BUREAU FILE. . . . . . . . .
NO. .................
1:) <:""t'OLt\ Q_~~l\~ ~ 'tJ\i\'E:.~ 0"-\ T~t'\~ER "SW~T<.l FoR DRY
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61\\ --r-kE. \JR-P. S" 6~LD Do A "f;.u.RV sy,
G4550Rl-3
..r'ECTION REPORT
l"O....""._"."""._"..............~........._.::..:....
CONFERRED WITH
""'/t::!t(f/
REPORT..OF INSPECTION
per NFPA 13&.25
REPORr~~.;. ~\L~~tJ\~lliT. ~L~cp -
STAEeT''?!,~.~ ~tc..~~ PK\N"{ N~, .
CITY & STATE" ,ort 1-1\ kE. f\I\ N ~ ZIP Ss.~ "') ~
~ -
ATT.
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NO... m.;,"..""_ ................"..mmm.:...............
BUREAU fiLE m"""""""...."m:""........
'NO. ..."._...m'......"..,...:....":,,;;..."" "'"...m."..."....
. SET 1 OF2
BUILDING~.~. AT. I IN. s. PE.C.TEO~f\lV\.. . ~..'..
INSPECTO '., . "
SG OFFlCEMti> k. . PHONENO.~'1- ~O
DATI: ~_-~~ .O(jJ \, .
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1. GENERAL
A. (To be answered by the Owner or Owners representative)
a. Have there been any changes in the occupancy classification, machinery or operations since the last inspection?
b. Have there been any changes or repairs to the fire protection systems since the last inspection?
c. If a fire has occurred since the last inspection, have all damaged sprinkler system components been replace<j?
d. Has the piping in all dry systems been checked for proper pitch wiihin the Past five years?
Date last checkeli
e. Has the piping in all systems been checked for obstructive materials?
Date last checkeli (checking is recommended at least every 5 years)
L 1-la1lEl all fire pu~ been te~ed to their full capacity thtouQh the use of hose streams or flow meters within the past 1 Z months?
g. Are g-raVily, surface 'or pressure-tanks protected from freezing? .' , .
h. Are any of the sprinklers 50 years old or older? (testing and/or replacement is recommended for such sprinklers)
i. Are any extra high temperature solder sprinklers regularly exposed to temperatures near 3000F?
B. (To be answered by the inspector)
a. Have the sprinkler systems been extended to all visible areas of the building?
b. Does there appear to be proper Clearance between the top of all storage and the sprinkler deflectOr?
c. Are the building areas protected bya wet system, heated, including its blind attics and perimeter areas, where accessible?
d. Are all visible exterior openinas protected against the entrance of cold air?
(checking Is recommended at least every 5 years)
<;.~ f-..
s,^p~~ t'\ ~I\\TA l..
2. CONTROL VALVES
a. Are all sprinkler system main control valves and all other valves in the appropriate open or closed position?
b. Are all control valves sealed or supervised in the open position?'
Control
Valves
No.
of
Valves
Type
Easily
Accessible
Yes No
Signs
Yes No
Valve
Open
Yes No
Secured?
If yes, how? lSealed?)
Locked?)
Yes No Supvd.?)
CITY CONNECTION
TANK
~I\,' "-\'T KC:btl\
SECTIONAL
SYSTEM \) 't<.."I
ALARM LINE
qr
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Test
Pipe
Location
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Flow
Pressure
::16
Static
Pressure
After
~.cs-
Pressure Fire Pump & Tank
Pressure Fire Pump & City
Pressure Fire Pump & Ponrl
Size Static
Test Pressure
Pipe Before
~A
3. WATER SUPPLIES . L
a. Water supply source? cityf>R 'O~ A K'E..
Waterflow Test Results Made During This Inspection
Test Size Static
Pipe Test Pressure .
_ Located Pipe Before
f~\)\<V R\~R =.l" L.l~
Gravity Tank
Flow
Pressure
Static
Pressure
After
4. TANKS, PUMPS, FIRE DEPT. CONNECTIONS
a. Do fire pumps, gravity, surface or pressure tanks appear to be in good external condition?
b. Are gravity, surface and pressure tanks at the proper pressure and/or water levels?
c. Are fire dept. connections in satisfactory condition, couplings free, caps or plugs in place and check valves tight?
d. Are fire dept. connections visible and accessible?
5. WET SYSTEMS 0 '. 1\
a. No. of systems' Make & Model t' ~ ~,
b. Are cold weather valves in the appropriate open or closed position?
If closed, has piping been drained?
c. Has the owner or owner's representative been advised that cold weather valves are not recommended by NFPA?
d. Have all the antifreeze systems been tecto"?
e. Date antifreeze systems were tested
f. The antifreeze tests indicate protection tn,'
system 1 2 3 4<; temperature
g. Did alarm valves, waterflow alarm indicators and retards test satisfactorily?
SG4550-R1-1 (2/05) IN,'URP,i'lCE BUREAU COpy
Yes N..6y:t: No'
~/
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tNot Applicable
"Explain (No) Answers on Back of Sheet 2
,r/r'
ASPECTION REPORT
NO.
tl/CD/::::U~ty / ~~~
REPORT OF INSPECTION
, PER NFPA 13 & 25
-ri---~ \N \ L ti"'\:<'M~ :"\1 . R.L~~
~T::E:~~~: t: ,,> .~&.Mrg.E ~t-1T"~'~?- A G
b. .Is the air preS$ure and pdmi6g water levels normal?
c.Did the alrOOinpressor operate satisfactorily?
d. . Were all low points drained during this ihspection?
e. Did all quick opening devices operatesatisfactoiily?
f. Did all the dry valves operate satisfactorily during this inspection?
g. Do dry valves appear to be protected from freezing?
h. Is the dry valve house heated?
INSPECTION CONTRACT
No.H9~..Y16~m
BUREAU FILE "....m....
NO............................".....................,....... "
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7. SPECIAL SYSTEMS
a. No. otsylll$RlS.... (')
TypE"
b. Were valves tested as required? . .
c. Did aU heat responsive systems operate satisfactorily?
"-1t."'Dtr:tN~ Yltbft"elttlr.'~te.dtlMng tesltlg?" ..~ .~""
Heat ResponSive Devices: Type Type of test
Valve N" 1 . .. . . . 2 . . . . . . 3 .. . . .. 4 . . . . . . 5 . . . . . . 6 .. . . . . Valve No
Valve No 1 . . . . . . 2 . . . . . . 3 . . . . . .4 . . . . . . 5 . . . .. . 6 . . . . . . Valve No
Valve No 1 . . . . . .2. . . . . .3. . . . . .4. . . . . .5. . . . . .6. . . . . . Valve No
Valve Nn, 1 . . . . . .2. . . . . .3. . . . . .4. . .. . .5. . . . . .6.. . . . . Valve No
Auxiliary equipment: N" r) Type i' J A
LocatiOlT-
Tll,'!tresultl. ,J
/.,
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'Make & Model
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1 . . . . . .2. . .. .. 3. . . . . .4. .. . . .5. . . . . .6. . . .. .
1..... .2..... .3..... .4. ,... .5.... ..6......
1..... .2..... .3..... .4..... .5... ...6......
1 . . . . . .2. .. . .. 3. . . . . .4. . . . . .5.. . . . .6. . . . ..
8. ALARMS
a. Did the water motors and gong operate during testing?
b. Did the electric alarms operate during ~sting?
c.. Did the supervisory alarms operate durihg teSting?
9. SPRINKLERS - PIPING
,a. Do sprinklers generally appear to be in good extemal condition?
b. Do sprinklers generally appear to be free of corrosion, paint, or loa9in9 and visible obstructions?
c. Are extra sprinklers aV'!ilable On the premises?
d. Does the exterior co~~i1Ion\ of piping, drain valves, check valves, hangers, pressure gauges, open sprinklers
and strainers appear'ia, be satisfactory?
e. Does the hand hose ori the sprinkler system appear to be in satisfactory condition?
10. EXPLANATION OF "NO" ANSWERS (For Sections lB thru 9):
~ ~r ~ \J.,-IJ'\JLt M F~\~ J
11. THE INSPECT8R SUQGESTSritEFOlLo*ING"NECESS"ARY IMPROVEMENTS, HOWelfER';T1U,SE SUGlESTlONS MiJ!NOT THE REsULT OF AN ENGINEERING SURVEY:
.~ \=~ ~\" PPI F M\::~ /
12. ADJUSTMENTS OR CORRECTIONS MADE:
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.
a:
13. LIST CHANGES IN THE OCCUPANCY HAZARD OR FIRE PROTECTION EQUIPMENT, AS ADVISED BY THE OWNER IN SECTION 1A:
~"
./
./
./
,
<:
'I,
14. INSPECTION AND SUGGESTED IMPROVE~TS 1E~E D1S~ WITH \HE UNDE~NED OWNER OR OWNER'~ REP~S~TATIV~
Signature of owner or owner's representative ~ . c~.._ . , r j,. , .~ --.:i:~ (__ Date _ . - ~.( ~ _ ^.!.::?
..- .
DUPLICATE TO'
STREET
CITY & STATF
ATT.
SG4550R2-2 (04"05)
ZIP
*Not Applicable
"Explain (No) Answers on Back of Sheet
INSURANCE BUREAU COpy
_.~~-~----_._---_._'-~..'r.._- --------.-.-~~___,=.-.- . ~.._ _--".=,==
"':'.~.'r;i ..
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~'1ca!. Fire ~ ... .....IT
StlCunty
DRY PIPE VALVE TRIP TEST RE~r
FOR -r-k \= ~~'5 t\I\ ~. ~ INSPf!CTION NO. J:I Cf ~.~ 1(')1-
STREET \ 4c:r9OX W'\ L~"" ~k\fD' N \tV CITYf. ~bk LAkf. S)ATE '" "LCONTFlACT NO.
DATE OF TRIP TEST ~ - ~ ~ . ()JO INSPECTOR Q d <rN.IJJA DAY WORK NO.
NOTE: BEFORE ANY DRY PIPE VALVE IS TRIP TESTED. THE WATER SUPPLY LINE T~JORQUqHLY FWSHI!D. THE TWO INCH DRAIN BELOW
THE VALVE SHOULD BE OPENED WIDE. AND WATER AT FULL PRESSURE SHOULD BE DISCHARGED LONG ENOUGH TO CLEAR THE PIPE OF ANY
ACCUMULATION OF SCALE OR FOREIGN MATERIAL. IF THERE IS A HYDRANT ON THE SUPPLY LINE. THIS HYDRANT SHOULD BE fW~HED BEFORE
THE TWO INCH DRAIN IS OPENED. THE DRIP VALVE ON THE DRY PIPE VALVE SHOULD BE CHECKED BEFORE TRIPPING THE DRY PIPE VALVE. TO SEE
THAT IT IS IN OPERATING CONDITION.
DRY PIPE VALVES
VALVE SERIAL NUMBER
MANUFACTURER (NAME)
VALVE MODEL
VALVE SIZE
CONTROLLING SPRINKLERS
(LOCATION)
(NUMBER)
DATE LAST TRIP TESTED?
DATE LAST OPERATED?
I AIR
PRESSURE BEFORE TEST
I WATER
SIZE AND LOCATION OF TEST VALVE
WAS GATE VALVE BELOW DRY VALVE OPEN WIDE AT TEST?
(IF NOT. HOW MANY TURNS?)
AIR PRIiSSURE
VALVE TRIPPED AT WATER PRESSURE
I TIME
IF SYSTEM FLOODED. LIST TIME WATER
REACHED TEST OPENING
PERFORMANCE
I INTERIOR OF BODY
I MOVING PARTS
I RUBBER FACING
I SEATS
I RESET?
DID ALARMS OPERATE AT TRIP TEST?
VALVE CONDITION
ALL LOW POINT DRAINS BLOWN OUT?
WATER CONTROL VALVE LEFT
OPEN AND SEALED?
ALARM CONTROL VALVE LEFT
OPEN AND SEALED?
QUICK OPENING DEVICES
DEVICE SERIAL NUMBER
MANUFACTURER (NAME)
TYPE AND MODEL
AIR PRESSURE IN UPPER CHAMBER
QUICK OPENING DEVICE TRIPPED AT
PERFORMANCE
aUICK OPENING DEVICE LEFT IN SERVICE
AND CONTROL OPEN AND SEALED?
SYSTEM NO. (
) I SYSTEM NO. (
SYSTEM NO. (
SYSTEM NO. (
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1=\(;
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INCH
INCH
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(APPROX)
(APPROX)
(APPROX)
(APPROX)
~ -\(')-05'
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MIN ~ \ SEC
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LBS
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LBS
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LBS
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LBS
LBS
LBS
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SEC
SEC
SEC
MIN
SEC
MIN
MIN
MI~ SEC
MIN
SEC
MIN
SEC
MIN
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SYSTEM NO. (N lS;V
/
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SYSTEM NO_ (
SYSTEM NO. (
SYSTEM NO. (
LBS
LBS
LBS
LBS
LBS
SEC
LBS
LBS
SEC
LBS
SEC
LIST ANY UNSATISFACTORY CONDITIONS:
REMARKS
$EE
'S uPf>L~ M ~N'TA,L
1:qCOJFite & / Simp/exGrinne//;
I Secunty ~_ H -". ~
INSPECTION REPORT d.. - cl ~ - O~
NO................. .
CONFERRED WITH ~~UP~LEMENTAL RECORD OF INSPECTION
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