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Kitchen Hood Fire System InspectiOn & Maintenance Report
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ANNUAL
INSTALLATION
LOCATION OF SYSTEM CYLINDERS
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Your Life Safety Specialists
4445 w. nth Sl., Suite 125, Minneapolis. MN 55435 (952) 893.0905
WET DRY CHEMIcAL
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CYLINDER SIZE SLAVE
FUSE LINKS 4500 F
FUSE LINKS 5000 F
OTHER
Name V(ys-lot'11L of ~'L>"( /..o./ie-
Address4CoP6 ;).,,<1[ ~104 Ave'-
cityDnD'("" LcJ(~ I MrJ .:57672
TelePhone('iS;))22Lo - 9 ZCCJ Store No.
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COOKING APPLIANCE LOCATIONS & SIZES: LEFT TO RIGHT
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FUEL SHUT-OFF
ELECTRIC
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GAS
SIZE
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LAST HYDRO TEST DATE
LAST RECHARGE DATE
SERIAL NUMBER
-::>-003/'/7
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MANUFACTURER'S MANUAL REFERENCE
NOTE: NON COMPLIANT 'Y'T~MS MAY FAIL TO &X1'INGUISHI SUPPRI!SI A FIRE.
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1. System interlocked w~h building fire alarm PI' 0 0 20. Check travel of cable nuts! 8-hooks 0 0 9i'
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4. System installed per UL 300 standard & meets 23. Proper clearance-flame to fi~ers ;If 0 0
manufacturers U,L listing & N.F.PA standards 9f 0 0 24, Exhaust fan in operating order p 0 0
5. Hood/duct penetrations sealed w~h weld or UL device f!. 0 0 25. All fi~ers replaced P' 0 0
6. Check if seals intact, evidence of tampering "9f 0 0 26. Fuel shut-off in on position J2f 0 0
7. ~ system has been discharged, report same 0 flJ 0 27. Manual & remote set/seals in place E'. 0 0
8. Pressure gauge in proper range (If gauged) 0 0 f? 28. Replace systems covers 2' 0 0
9. Check cartridge weight (If applicable) P' 0 0 29. System operational & seals in place 2 0 0
10. Dry system 6 y_ maintenance date! wet system 12 30. Slave system operational 0 o;!f
year hydro-test date % 0 0 31. Clean cylinder & mount ~ 0 0
11. Inspect cylinder and mount P' 0 0 32. Fan warning sign on hood 17 0 0
12. Operate system from tarminallink ~ Q L! 33. Proper signage and personnel instructed in manual
13. Test for, proper operation from remote J7 0 0 operation of system p: 0 0
14. Check operation of micro switch ;!J 0 0 34. Proper hand portable extinguishers 9f 0 0
15. Check operation of gas valve j!J 0 0 35. K class fire extinguisher in cooking area pf 0 0
16. Clean nozzles fi!! 0 0 36. Portable extinguishers properly serviced ';I 0 0
17. Proper nozzle covers in place ;If 0 0 37. Service & Certification tag on system 91 0 0
18. Check fuse links and clean jlJ 0 0 38. Safety chains on all gas appliances attached and secured j;;r' 0 0
19. Replaced fuse links Jlf 0 0 NOTE DISCREPANCIES OR DEFICINCIES BELOW 0 0 0
, COMMENTS:
On this date, the a ve system was tested and inspected in accordance with procedures of the presently adopted editions of
NFPA 17, 1 an the manufacturer's manual and was operated according to these procedures with results indiclJled above.
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SERVICE TECHNICIAN PERMIT NO. DATE: TIME: AM PM CUSTOME U ED AGENT
The above SetVice technician certifles that the system was personally inspected and found conditions to be as indicated on this report.
WHITE - CUSTOMER
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YELLOW - DISTRIBUTOR
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PINK - AUTHORITY HAVING JURISDICTION