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25 -78 INSPECTION, TESTING, AND MAIN` ENANCIr.OF WA'T'ER -BASED FIRE PROTECTION SYSTEMS
Inspection, Testing, and Maintenance Cover Sheet
NFPA 25 as amended by CCR, Title 19
Property Information:
Name: aJA'r,,ccupancy /Use:
Address: 9 ' / ! Costruction Type:
City; '( Y-QC s ' No. Stories:
ZIP;2oZJ Year Constructed:
Contact: ,,59
Telephone:Z2 1 b5 CJ -2_ FS'O
Contractor Information: L Number of System Risers
Number of Forms
A
FAIL*
Name: 1 Copy sent to:
Address:
jiff
Z d s, i< _ d-
05-
wrier Date 2
City: bgAucsc; •Q Id t Fire AHJ Date
State: CA VContractor Date
Private Water Supply System 7
NOTES: Telephone: '/11
1) For specific inspection, testing, and
CA License #5 I maintenance requirements and information,
see NFPA 25, 2002 Edition as amended by
Job # California Code of Regulations, Title 19, §901
to gsos.
Performed by;
Print) 2) Inspection Items may be performed by the
11
Owner In accordance with California Code of
Note: Contractor information may be pre - printed Reaulations-Tltle 19 6904.1(a)
Forms included with this report NFPA 25
Chapter Number of Forms N/A FAIL* PASS
Automatic Sprinkler System 5
Standpipe and Hose Systems 6
Private Water Supply System 7
Fire Pump 8
Water Storage Tank 9
Water Spray System 10
Foam Water Sprinkler System 11
See "Deficiencies and Comments" section at end of each respective fo
State Fire Marshal AES 1 March 21, 2006
Inspection, Testing, and Maintenance Fire Sprinkler System
NFPA 25 Chapter 5 as amended by CCR Title 19
Date of Inspection, Testing, Maintenance: + -w C System Riser ID:
Property Information:
Name: y U( L,.S ( rn . Type
Wetst
Pipe
Address: D ry Pipe
Preaction
Deluge
City: 66 Ke rSC e ld C 6,
C
Page 1
wicn, urain i est rcesuits:
Initial Static Pressure: (psi)
Residual Pressure: '7` (psi)
Restored Static Pressure: (o ( (psi)
Abbreviation Key:
1 = Inspection
T = Test
M = Maintenance
A -O = After Operation
MI = Per Manufacturer's Instructions
Item Activity Frequency Description NFPA 25
Reference Fail N/A Pass
1.1 1 Daily
Weekly
Preaction /Deluge Valves - Enclosure
temperature 12.4.3.1
1.2 1 Daily
Weekly Dry Pipe Valves - Enclosure temperature 12.4.4.1.1
1.3 1 Quarterly Gauges (Dry, Preaction, Deluge Systems) 5.2.4.2
5..2.4.3 .3
1.4 1 Quarterly Control Valves 12.3.2.1
1.5 1 Quarterly Alarm Devices 5.2.6
1.6 1 Quarterly Gauges (Wet Pipe Systems)
1.7 1 Quarterly Hydraulic nameplate 5.2.7
1,8 1 Quarterly Sprinklers 5.2.1
1.9 1 Quarterly Spare Sprinklers 5.2.1.3
1.10 1 Quarterly Fire Department Connections 12.7.1
1.11 1 Quarterly Alarm Valves - Exterior Inspection 12.4.1.1
1.12 1 Quarterly Preaction /Deluge Valves - Exterior Inspection 12.4.3.1.6
1.13 1 Quarterly Pressure Reducing Valves 12.5.1.1
1.14 1 Quarterly Dry Pipe Valves - Exterior Inspection 12.4.4.1.4
1.15 1 Quarterly Backflow Preventers 12.6.1
1.16 1 Annually Pipe and Fittings 5.2.2
1.17 r-171 Annually Buildings 5.2.5
State Fire Marshal AES 2 June 17, 2008
Inspection, Testing, and Maintenance Fire Sprinkler System Page 2 of
NFPA 25 Chapter 5 as amended by CCR, Title 19
Date of Inspection, Testing, Maintenance: 3 --/ System Riser ID:
Property Information:
Name: t
Type of ystem: ,o A4,1tVP.E n 1 k °p C 7/^ Wet Pipe Q,` 0
urn Dry PipeAddress: d Preaction
Deluge
M
City: I d
Item Activity Frequency Description NFPA 25
Reference Fail N/A Pass
1.18 1 Annually Hangers 5.2.3
1.19 1 Annually Seismic Braces 5.2.3
1.20 1 5 Years Hangers (Accessible concealed spaces) 5.2.3.3
1.21 1 5 Years Seismic Braces (Accessible concealed
s aces 5.2.3.3
1.22 1 5 Years Pipe and Fittings (Accessible concealed
spaces) 5.2.2.3
1.23 1 5 Years Sprinklers (Accessible concealed spaces) 5.2.1.1.4
1.24 1 5 Years Alarm Valves — Interior Inspection 12.4.1.2
1.25 1 5 Years Alarm Valves - Strainers, filters, orifices 12.4.1.2
1.26 1 5 Years Check Valves — Interior Inspection 12.4.2.1
1.27 1 5 Years Preaction /Deluge Valves — Interior Inspection 12.4.3.1.7
1.28 1 5 Years Preaction /Deluge Valves - Strainers, filters,
orifices 12.4.3.1.8
1.29 1 5 Years Dry Pipe Valves — Interior Inspection 12.4.4.1.5
1.30 1 5 Years Dry Pipe Valves - Strainers, filters, orifices 12.4.4.1.6
2.1 T Annually Alarm Devices (90 Sec) 5.3.3
12.2.7
2.2
2.3
T
T
Annually
Annually
Main Drain Test (Enter data on Page 1)
Antifreeze Test
12.2.6
12.2.6.1
12.3.3.4
5.3.4
2.4 T Annually Control Valve - Position 12.3.3.1
2.5 T Annually Control Valve — Operation 12.3.3.1
16 T Annually Supervisory 12.3.3.5
2.7 T Annually Preaction Valve - Priming Water 12.4.3.2.1
2.8 T Annually Preaction Valve — Low Air Pressure Alarm 12.4.3.2.10
State Fire Marshal AES 2 June 17, 2008
Inspection, Testing,'and Maintenance Fire Sprinkler System Page 3 of 4 /
NFPA 25, Chapter 5 as amended by CCR. Title 19
Date of Inspection, Testing, Maintenance: — System Riser ID:
Property Information:
Name; , ( Type of ystem: dr cq;
et Pipe Q 4x
Dry Pipe` Address: -
Preaction u, y
Deluge b f.
IRE N
City:
Item Activity Frequency Description NFPA 25
Reference Fail N/A Pass
2.9 T Annually Preaction Valve — Full Flow Trip Test 12.4.3.2.2
2.10 T Annually Dry Pipe Valve — Priming Water 12.4.4.2.1
2.11 T Annually Dry Pipe Valve — Low Air Pressure Alarm 12.4.4.2.6
2.12 T Annually Dry Pipe Valve — Quick- Opening Device 12.4.4.2.4
2.13 T Annually Dry Pipe Valve — Trip Test 12.4.4.2.2
2.14 T Annually Backflow Preventer Assemblies 12.6.2
2.15 T 3 Years Dry Pipe Valve — Full Flow Trip Test 12.4.4.222
2.16 T 5 Years Gauges 5.3.2
2.17 T 5 Years Pressure Reducing Valve 12.5.1.2
2.18 T 5 Years Fire Department Connection Backflush 12.7.4
2.19 T 5 Years Sprinklers — Extra High Temperature 5.3.1.1.1.3
2.20 T 5 Years Sprinklers — Corrosive environment or
corrosive water 5.3.1.1.2
2.21 T 10 Years Sprinklers - Dry 5.3.1.1.1.5
2.22 T 20 Years Sprinklers - Fast Response 5.3.1.1.1.2
2.23 T 50 Years Sprinklers 5.3.1.1.1
2.24 T 75 Years Sprinklers 75 years in service 5.3.1.1.1.4
2.25 T Sprinklers manufactured prior to 1920 —
Replace 5.3.1.1.1.1
3.1 M Annually Control Valves 12.3.4
3.2 M Annually Preaction /Deluge Valves 12,4.3.3.2
3.3 M Annually Dry Pipe Valves /Quick - Opening Devices 12.4.4.3.2
3.4 M Annually Dry Pipe Valve — Low Point Drains 12.4.4.3.3
3.5 M 5 Years Obstruction Investigation Chapter 13
State Fire Marshal AES 2 June 17, 2008
Inspection, Testing, and Maintenance Fire Sprinkler System Page 4 of d
NFPA 25, Chapter 5 as amended by CCR Title 19
Date of Inspection, Testing, Maintenance: ? System Riser 1D:
Property Information:
9
Type ofs cA 4)
d1ttName: IHWtPipe
Address: Dry Pipe 4
Preaction
Deluge v
City: CwKr YS
Deficiencies and Comments:
Item Deficiencies and Comments Item number must correspond to the Item number
of the Activity listed above:
SS e Continuation Page(s) _ (Indicate t umber of continuation pages)
f ASS
FAIL. /a
Signature Date
State Fire Marshal AES 2 June 17, 2008