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AUTOMATIC SPRINKLER CO.
Setting The S#;~,ndard...
1301 L'Orient Street
St. Paul, Minnesota 55117
(651) 558-3300 . (800) 229-6263
Fax: (651) 558-3310
SHEET 1 012- Use separate sheet lor each building inspected
MINNESOTA LICENSE NO. COOS
AGREEMENT AND REPORT OF INSPECTION
ilINSPECTION Z (' :S Z
BUILDING OR LOCATION i,; \[ OJ '>
INSPECTOR [ift ,[ (
DATE Z '10 -jt
OffICl
REPORT TO 0'.....:.'.' \ \1 (\oft ,\ i
STREET ~
CITY & STATE L, . ,
F'
Owner hires Viking Automatic Sprinkler Company to conduct an inspection of the fire suppression system at the above location or building, and
prepare a written report of that inspection for an agreed upon fee. As part of this agreement, owner agrees to terms and conditions on rear of form and
will complete the Owner's Section of this document.
Owner's Section (To be answered by Owner or Occupant)
A. Explain any occupancy hazard chanp;es since the previous inspection: "
B. Describe fire protection modifications made since last inspection:
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C. Describe any fires since last inspection:
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D. When was the system pipinp; last checked for stoppap;e, corrosion or foreip;n material?
E. When was the dry-pipinp; system last checked for proper pitch?
F. Are dry valves adeJ,juately protected from freezing?
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Title
Date
Inspector's Section (All responses re nce current inspection) N/A = NOT APPLICABLE
1 General
a. Is the building occupied? ri'Yes D No
b. Are all systems in service? ~es D No
c. Does there appear to be a minimum of 18 in. (457 mm) clearance between the top of the storage and the sprinkler deflectors? .-rYes n No
d. Does the valve hose on the sprinkler system(s) appear to be satisfactory? DYes [J No crKr/ A
2 Control Valves (See Item 15)
a. Do sprinkler system control valves appear to be in the appropriate open or closed position? dYes n No
b. Are control valves in the open position locked, sealed or equipped with a tamper switch? DYes D No
3 Water Supplies (See Item 16).----.---.-------
a. Was a water flow test of main drain made at the sprinkler riser(s)? lif"Yes D No
4 Tanks, Pumps, Fire Department Connections
a. Are fire pumps, gravity tanks, reservoirs and pressure tanks in good condition and properly maintained? DYes n No wN/ A
b. Are fire department connections in satisfactory condition, couplinp;s free, caps in place, and check valves tip;ht? ,la"'fes uNo D N/ A
Are they accessible and visible? ,B"Ves D No [J N/ A
5 Wet Systems
a. Are cold weather valves (0.5. & Y.) in the appropriate open or closed position? DYes n No I'fN/ A
b. Have antifreeze system solutions been tested? [] Yes D No l'l'N/ A
c. Were the antifreeze test results satisfactory? DYes D No Ll N/ A
d. In areas protected by wet system(s), does the building appear to be properly heated in all areas, including blind attics and perimeter areas
where accessible? ,13'''I'es D No [] N/ A Do all exterior openings appear to be protected a~ainst freezing?JAes D No D N/ A
6 Dry System (See Items 11 to 13)
a. Are dry valves (s) in service? DYes DNo DN/A
b. Are the arrpressu.res and priming water levels in accordance with the manufacture's instructions? DYes [] No D N/ A
c. Has the operation otl:he-ajr or nitrogen supplies been tested? DYes [] No D N/ A Are they in service? DYes D No [] N/ A
d. Were all know low points d1-1riftel;i during this inspection? DYes D No D N/ A
e. Did quick-openinp; devices operate"~~ctorily? DYes [1 No D N/ A
f. Did the dry valve(s) trip properly durinp; ~p pressure test? [] Yes D No LJ N/ A
g. Did the heating equipment in the dry-pipe val~e room(s) operate at time of inspection? DYes D No [] N/ A
7 Special Systems (See Item 14)
a. Did th~.deluge or pre-action valves operate properly during testing? [J Yes LJ No [] N/ A
b. Did the hea1:responsive devices operate properly during testing? DYes D No D N/ A
c. Did supervisory d~~Ii::eti.,Qperate durinp; testing? DYes D No [] N/ A
8 Alarms
,,/
a. Did water motor(s) and gong(s) test satisfactorily? n Yes uNo QN/ A
b. Did electric alarm(s) test satisfactory? !7'Yes D No D N/ A
c. Did supervisory alarrn service test satisfactory? D'Yes D No D N/ A
9 Sprinklers
a. Do visible sprinklers appear to be free from corrosion, loading or obstruction to spray discharge? goo/fes D No
b. Are sprinklers less than 50 years old? (Older sprinklers require sample testing) lA"f es D No
c. Are quick response and residential sprinklers less than 20 years old? (Older sprinklers require sample testing) ~es D No D N/ A
d. Is stock of spare sprinklers available? o--'i'es LJ No
e. Does the exterior condition of sprinkler system appear to be satisfactory? JJ"Yes D No
f. Do visible sprinklers appear to be of proper temperature ratinp; for their locations? ;;)Xes Ll No
10 Explain any "No" answers and comments:
Signature:
(Rev. 2/8/(6)
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Date:
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AUTOMATIC SPRINKLER CO.
Setting The &tandard...
1301 L'Orient Street
St. Paul, Minnesota 55117
(651) 558-3300 . (800) 229-6263
Fax: (651) 558-3310
Inspection Report
No. 7-t.,..J3 -i~ :~ "'r
System No. or Description if multiple
systems
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SHEET 2 of 2 - Use separate sheet for each system inspected
11 Date dry-pipe valve trip tested (control valve partially open)
12 Date drY~~_vaIve trip tested (control valve fully open)
13 Date quick-opeiung..~evice tested
.,~
(See Trip Test Table which follows)
(See Trip Test Table which follows)
(See Trip Test Table which follows)
DRY PIPE
OPERATING
TEST
DRY VAL '- TRIP TEST TABLE O.O.D.
MAKE '~~-,..."" MODEL SERIAL NO. MAKE MODEL SERIAL NO.
,..~...~
Time to Trip Water ..........~. Air Trip Point Time Water Reached Alarm Operated
Thm Test Pipe Pressure "~, ,Pressure Air Pressure Test Outlet Properly
MIN. SEe. PSI l"9f_ PSI MIN. SEe. YES NO
Without --.... ........................
Q.O.D
With ,""
Q.o.D ............... '.
14 Date deluge orpreaction valve tested
(See Trip Test Table whichJollaws)
TRIP TEST TABLE
DELUGE &
PRE ACTION
VALVES
Operation (j'PNEUMA TIC D ELECTRIC D HYDRAUUC
Piping Supervised D~. D NO IDetecting Media Supervised DYES D NO
Does valve operate from the manual trip an~emote control stations DYES D NO
Is there an accessible facility in each circuit for testing'......." D YES D NO I Method ofTesting Circuits
-, Does each circuit operate Does each circuit Maximum time to
',.
MAKE MODEL s~ision loss alarm operate valve release operate release
YES '---l NO YES T NIT YES I NO
I ~............. I I
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15 See Control Valve Maintenance Table
CONTROL VALVE MAINTENANCE TABLE
Explain
Abnormal
Control Valves Number Tvpe Open Secured Closed Signs Condition
City Control Valves J i" i .' v. / ,
Bypass Valves ,
Tank Control Valves
Pump Control Valves
Sectional Control Valves
System Control Valves 1 r \ '...- '../ j 'I,. ' 4.__.,
, 'J,
Other Control Valves
Kitchen Control Valves
16
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1(,
Tank
(j.;
Last Water Flow Test
This Water Flow Test
Test Pipe
Location
Size of
Test Pi e
Static
Pressure
,:; i
Pum (
Residual
(Flow)
Pressure
i'
'71- !.
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?- ~~.
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17 Explain any "No" answers and comments:
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:
Signature: 11 AA.Q 0 (-)
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Date: 7: i [,) vi
(Rev. 2/8/06)