HomeMy WebLinkAboutINSP. TEST MAINTEN. FIRE EXTINGUISH-12/22/2011Inspection, Testing, and Maintenance AES20 Page 1 of
Wet°nemical Pre - Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7
Property Information:
Appliance Name Total
Flow Pts
Nozzle
Type
Name:
a
2
Address:
3
JORGENSEN COMPANY
City: ,, , ! }
4
2691 South East Ave. System
I. CZIP: ,3 1
5
Fresno, CA 93706 t' of
6
C16 Lie. # 262995
Contact:
7
Telephone: rte, a S (( Service Location:
Date: /
2691 S. East Ave Fresno 800 - 481 -3473
El 1536 Princeton Modesto 800- 606 -0835Copysentto:. (r A" 'L
Owner `"
t-
Date I E' 2345 S. Fruitvale Bakersfield 877 - 238 -6305
PASS
FAIL
Fire AHJ Date 3190 Luyung Dr Rancho Cordova 800 - 758 -1124
Service Technician. C' Owner /Occupants
Print Name ,n ir nE Print Name ( (i tt
7 i
NOTES 1) For specific inspection, testing, and maintenance requirements and information, see California Code of Regulations, Title 19,
Division 1, Chapter 5, §901 to §906
2) Inspection items may be performed by the property owner in accordance with CCR Title 19, Division 1, Chapter•5.` §904.7
System Location Wwd; i S, -UL AT'- System Mfg Ask Model # It "ion T
Hoods 1 Dimension(s)
I
Plenums i Dimensions(s) J Standard V -Bank
Ducts ( Dimensions(s)
p ti
Fuel /Heat Shut Off: Gas # Electrical # Integral Make Up Air Shut Down Yes No
Cylinder Size(s) & Qty _3"" I Last Hydrostatic Test Date(s) "11 ! Flow Points: Capacity / a Used 7
COOKING APPLIANCE LOCATIONS: LEFT TO RIGHT WITH SIZES AND COVERAGE NOZZLES
Appliance Name Total
Flow Pts
Nozzle
Type
Nozzle
Qty
Appliance Name Total
Flow Pts
Nozzle
Type
Nozzle
Qty
2
3 4
5 6
7 8
FIXED TEMPERATURE- SENSING ELEMENTS (SUCH.AS- FUSIBLE LINKS)
QTY TEMP MFG DATE INSTALL DATE QTY TEMP MFG DATE INSTALL DATE
St;;te i;„ A M;arghal AE2-9 Test Form 1012010
Inspection, Testing, and Maintenance AES20 Page 2 of
Wet .,hemical:Pre -En ineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7
Property Address:'
C°
Date:
System Location: System of
Contractor Name: JORGENSEN COMPANY
Item Frequency Description NFPA 17A Fail N/A Passunlessnoted)
1 -1.1 Monthly
Manual Actuators are Unobstructed 7 2 2(2) i.e. remote pull station
1 -1.2 Monthly Tamper Indicators and Seals Intact 7.2.2(3)
1 -1.3 Monthly Maintenance Tag in Place CCR T -19 906
1-1.4 Monthly No Obvious Physical Damage 7.2.2(5) L--'
1 -1.5 .. Monthly Gauge Readings within Proper Limits (Stored Pressure) 7.2.2(6)
1 -1.6.. Monthly Blow -Off Caps in Place & Undamaged 7.2.2(7)
1.7 Monthly Hoods, Ducts, Filters in Place and Clean CFC 904.11.6.3
1 -1.8 Monthly Hood, Ducts & Protected Cooking Appliances Have Not Been 7 2 2(8) Replaced Modified or Relocated
T -1 Semi Annually Automatic Detection /Manual Activation Functioned Correctly 7.3.2.3
T -1.2 Semi Annually Alarm Signals Functioned Correctly 7.3.2.3
T -1.3 Semi Annually Fuel Shut Off Operated Correctly 7.3.2.3
T -1.4 Annually Regulator Tested and is Within Acceptable Limits 7.3.2.3 tr
T -1.5 Semi Annually Manual Reset Relay Functioned Correctly (if applicable) 7.3.2.3
M -1.1 Semi Annually Complete All Inspection Items (1 -1.1 through 1 -1.8)
M -1.2 Semi Annually All Agent Containers within Acceptable Hydrostatic Test 7,5.1 1 L.--' Dates
M -1.3 Semi Annually All Auxiliary Pressure Containers and /or Hose Assemblies 7.5.1(2)(3) L__ Within Acceptable Hydrostatic Test Dates
M -1.4 Semi Annually Cartridge Weights within Acceptable Limits 7.3.2.1(2) 1--
M-1.5 Semi Annually Liquid Level Within Acceptable Limits (Non- Pressurized) 7.3.2.1(2)
M -1:6 Semi Annually No Signs of Corrosion in Agent Cylinder (Non- Pressurized) 7.3.2.1(2)
M -1.7 Semi Annually Distribution Piping Unobstructed and Contiguous 7.3.2.1(3) Z'
M -1.8 Semi Annually Nozzles are Correct, Clean & Properly Aimed 7.3.2.1(2) it
M -1.9 Semi Annuallyy ixed Temperature Sensing Elements Maintained or CFC 514.2.2Replaced
M -2.0 Semi Annually Auxiliary Equipment Such as Water Valves Functioned 7.3.2.1(2) G Correct)
M-2.1 6 Year Internal Maintenance as Required by the Manufacturer CCR T -19 904.7
I = Insoection M = Maintenance T = Test For additional deficiencies and comments use AES 9
Item Deficiencies and Comments: Deficiencies and Comments Item number must correspond to the Item number of the Activity listed above:
System Inspected, tested and maintained in accordance with manufacturer's written instructions-and-a licable standards (T-19 §904.7)
a 0 4 1
PASS l/ { ,
FAIL/ Technician - Signature Date & Time of Service -''Customer Acknowledgement
State EOrc Marshal AEC 20 Test Form 1012010
a
Inspectigji, Testing, and Maintenance AE 20 Pagel of r?
Wel,Ch`emical Pre - Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7
Nozzle
Property Information:
Appliance Name Total
Name:
Nozzle
Address: c ct.(r- ((vii JORGENSEN COMPANY
Qty
City: 2691 South East Ave. System
ZIP: s v
Fresno, CA 93706 ca of
C16 Lic. # 262995
2
Contact:
Telephone: v b ° 5 (
Service location:
Date:
A l `
2691 S. East Ave Fresno 800- 481 -3473
Princeton Modesto 8007606 -0835
PASSCopysentto: i(, r '
Fk Owner l ' Date 1 " (t
01536
d2345 S. Fruitvale Bakersfield 877 - 238 -6305 El
Fire AHJ Date 3190 Luyung Dr Rancho Cordova 800 - 758 -1124 FAIL
Service Technician ;Irr, i (r ,a° ' "' "- Owner /Occupank '
Print Name _ ( AIL AI-V e' A Print Name x 1 'rn r, G*"'? c,)76y, f e
U
NOTES 1) For specific inspection, testing, and maintenance requirements and information, see California Code of Regulations, Title 19,
2
Division 1, Chapter 5, §901 to §906
5 `
2) Inspection items may be performed by the property owner in accordance with CC Title 19, Division 1, Chapter 5 §904.7
System Locationyy}'W`-,ou 0Ai to Sint(( A r' System Mfg Af - )'^ t Model #
t A l
Hoods Dimension(s) I c `
I _
Plenums Dimensions(s) Standard V -Bank
Ducts ( Dimensions(s) 2 L
Fuel /Heat Shut Off: Gas # Electrical # Integral Make Up Air Shut Down eYes No
Cylinder Size(s) & Qty Last Hydrostatic Test Date(s)V- vy ? Flow Points: Capacity Used l
COOKING APPLIANCE LOCATIONS: LEFT TO RIGHT WITH SIZES AND COVERAGE NOZZLES
Appliance Name Total Nozzle Nozzle Appliance Name Total Nozzle Nozzle
Flow Pts Type Qty Flow Pts Qty
2
A l ` o"
Type
d i u I
3 4
F f, i, n U t FA y 2 3.
5 ` 6
7 8
FIXED TEMPERATURE - SENSING ELEMENTS (SUCH AS FUSIBLE LINKS)
QTY TEMP MFG DATE INSTALL DATE QTY TEMP MFG DATE INSTALL DATE
So(? D, a (I'
State Ciro Mapshal ACS 20 Test Form 1012010
Inspection, Testing, and Maintenance AES2 Page 2 of
Wet heroical Pre -En ineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7
Property Address:
Date:
System Locationy System of -
1, t`L l,t CJ !•-. A }. i
Contractor Name: JORGENSEN COMPANY
Item Frequency Description NFPA 17A
unless noted)
Fail N/A Pass
1.1 Monthly
Manual Actuators are Unobstructed 7'2.2(2) t/ i.e. remote pull station)
1 -1.2 Monthly Tamper Indicators and Seals Intact 7.2.2(3) rl
1 -1.3 Monthly Maintenance Tag in Place CCR T -19 906
1 -1.4 Monthly No Obvious Physical Damage. 7.2.2(5) t/
1 -1.5 Monthly Gauge Readings within Proper Limits (Stored Pressure) 7.2.2(6)
1 -1.6 Monthly„ Blow -Off Caps in Place & Undamaged 7.2.2(7)
1 -1.7 Monthly Hoods, Ducts, Filters in Place and Clean CFC 904.11.6.3
1 -1 :8 Monthly Hood, Ducts & Protected Cooking Appliances Have Not Been 7 2 2(8) Replaced Modified or Relocated
T -1 Semi Annually Automatic Detection /Manual Activation Functioned Correctly 7.3.2.3
T -1.2 Semi Annually Alarm Signals Functioned Correctly 7.3.2.3
T -1.3 Semi Annually Fuel Shut Off Operated. Correctly 7.3.2.3 c/
T -1.4 Annually Regulator Tested and is Within Acceptable Limits 7.3.2.3
T -1.5 Semi Annually Manual Reset Relay Functioned Correctly (if applicable) 7.3.2.3
M -1.1 Semi Annually Complete All Inspection Items (1 -11 through-1 -1.8)
M -1.2 Semi Annually All Agent Containers within'Acceiptable Hydrostatic Test 7.5.1(1)
r., Dates
M -1.3 Semi Annually All Auxiliary Pressure Containers `and /or Hose Assemblies 7.5.1(2)(3) 1 - Within Acceptable Hydrostatic Test Dates
M -1.4 Semi Annually Cartridge Weights within Acceptable Limits 7.3.2.1(2) s
M-1.5 Semi Annually Liquid Level Within Acceptable Limits (Nn- Pressurized) 7.3.2.1(2)
M -1.6 Semi Annually No Signs of Corrosion in Agent Cylinder (Non- Pressurized) 7.3.2.1(2)
M -1.7 Semi Annually Distribution Piping Unobstructed and Contiguous 7.3.2.1(3)
M -1.8 Semi Annually Nozzles are Correct, Clean & Properly Aimed 7.3.2.1(2) t-
M-1.9 Semi Annually Fixed Temperature Sensing Elements Maintained or CFC 514.2.2 liReplaced
M -2.0 Semi Annually Auxiliary Equipment Such as Water Valves Functioned 7.3.2.1(2)
Correctly
M -2.1 6 Year Internal Maintenance as Required by the Manufacturer CCR T -19 904.7 4--
I = Inspection M = Maintenance T = Test For additional deficiencies and comments use AES 9
Item Deficiencies and Comments: Deficiencies and Comments Item number must correspond to the Item number of the Activity listed above:
System Inspected, tested and maintained in accordance with manufacturer's written instructions and a plicable standards (T -19 §904.7).
b PASS' (J-tXP- G •. , e --- ( / / v a f/ 1'.C C.' _
FAIL, Technician Signature Date & Time of Service — Customer Acknowledgement
State Eire Marshal AEC 20 Test Form 1012010
l( -
tat
Ow