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25 -78 INSIIEC'1'ION,'I'CSTING, AND MAINTGNANCB.OP :VA'1'ER -BASED FIRE• PROTECTION SYSTEMS
1
Inspection, Testing, and Maintenance Cover Sheet
NFPA 25 as amended by CCR, Title 19
Property Information: /
QN( %%1, Name: r'V2V" lV cfZ4 Occupancy /Use:
Address: k e, %QjConstruction Type:
City: No. Stories:
1j
ZIP: - Year Constructed:
Contact: iC A _
Telephone: S 7
Contractor Information: Number of System Risers
Name:. Copy sent to:
Address: U">1 / n Yj e Owner Date 3-23;V-_2
City: IL +` I: LD r* Fire AHJ Date --ZCI'
State: C6 (Contractor Date 3 -2-C (&,
Telephone: (i /4 NOTES:
C 2-11
1) For specific inspection, testing, and
CA License# O Q maintenance requirements and Information,
see NFPA 25, 2002 Edition as amended by
Job // California Code of Regulations, Title 19, §901
y
A'/ ` to §906.
Performed b : C/ J e
Print) 2) Inspection Items may be performed by the
Owner in accordance with California Code of
Note: Contractor information may be pre - printed Regulations Title 19 904.1 a
Forms Included with this report FP.At25 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 form.
State Fire Marshal AES 1 March 21, 2006
Inspection, Testing, and Maintenance Fire Sprinkler System Page 1 of 4NFPA25Chapter5asamendedbyCCRTitle19
Date of Inspection, Testing, Maintenance: System Riser ID:
Property Information:
vv II Type of stem: ofc.4 Name: K l L V-Y- Ct <r,otT{ et Pipe
ll ( Dry Pipe\ Address:
Preaction
Deluge /P
City: ct f ey_ —1_,.e 0A
G
Main Drain Test Results:
Initial Static Pressure: (psi)
Residual Pressure: e (psi)
Restored Static Pressure: (psi)
Abbreviation Key:
I = 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
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) 5.2.4.1
1.7 1 Quarterly Hydraulic nameplate 5.2.7
1.8 1 Quarterly Sprinklers 5.2.1 r
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 1 Annually Buildings 5.2.5
State Fire Marshal AES 2 June 17, 2008
Inspection, Testing, and Maintenance Fire Sprinkler System Page 2 of 4
NFPA 25 Chapter 5 as amended by CCR Title 19
Date of Inspection, Testing, Maintenance: — Z System Riser ID:
Property Information:
4it
NFPA 25
Reference
Name:
Type o ystem: of
Wet PiperVZe
jAddress: c 1 -dG 9fP Dry
PreactionPreaction 1.
1
Deluge
Hangers
E MPS
City:
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
spaces)
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
f
2.2 T Annually Main Drain Test (Enter data on Page 1)
12.2.6
12.2.6.1
12.3.3.4
2.3 T Annually Antifreeze Test 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
2.6 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: i (.()et Type o ystem: o c !A
C!'/o Wet Pipe
1A
Address: F I1 !e ( Dry Pipe -
Preaction d
Deluge
City: cq
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 12.4.4.2.2.2
2.16 T 5 Years Gauges 5.3.2
i
2.17 T 5 Years Pressure Reducing Valve 12.5.1.2
2.18 T 5 Years Fire Department Connection Backflush 12.7.4
i
2.19 T 5 Years Sprinklers — Extra Nigh Temperature 5.3.1.1.1.3
I 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
I
2.24 T 75 Years Sprinklers 75 years in service 5.3.1.1.1.4
2.25 T Sprinklers manufactured prior to 1920 —
Re lace 5.3.1.1.1.1
3.1 M Annually Control Valves 12.3.4
3.2 M Annually Preaction /Deluge Valves 12.4.3.12
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 ,tune 17, 2008
Deficiencies and Comments:
Item Deficiencies and Comments Item number must correspond to the Item number
of the Activitv listed above:
Vee Continuation Page(s) _ (Indicate the number of continuation pages)
V PASS
FAIL
Signature Date
State Fire Marshal AES 2 June 17, 2008
Inspection, Testing, and Maintenance Fire Sprinkler System
NFPA 25 Chapter 5 as amended by CCR Title 19
Page 4 of 4
Date of Inspection, Testing, Maintenance: System Riser ID:
Property Information:
YC
Address:
92 -4Y
l"""
Type of System:
et Pipe
Dry Pipe
Preaction
Deluge
9 t ipI . 1ZIName:
u
U
City
Deficiencies and Comments:
Item Deficiencies and Comments Item number must correspond to the Item number
of the Activitv listed above:
Vee Continuation Page(s) _ (Indicate the number of continuation pages)
V PASS
FAIL
Signature Date
State Fire Marshal AES 2 June 17, 2008