HomeMy WebLinkAbout920 34THInspection, T-qsting, and Maintenance % A€S20 Page 1 of
Wet Chemical Pre- Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7
Property Information:
Nozzle
Qty
Appliance Name
4- ZZ
Nozzle
Qty
Name:
2 2 ?U
Address:' _ /_ JORGENSEN COMPANY
City: AV4 2691 South East Ave.
Fresno, CA 93706
System
ZIP: of /
C16 Lic. # 262995
Contact:
Telephone: a I Service Location: 7 .22 / Date.' . !
2691 S. East Ave Fresno 800 - 481 -3473
1536 rinceton Modesto 800 - 606 -0835 PA$SCopysentto:
El owner Date p 32 45 S. Fruitvale Bakersfield 877 - 238 -6305
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Fire AHJ Date El 3190 Luyung Dr Rancho Cordova; 80,0- 758 -1124
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A- Service Technician Owner /Occupant
Print Name µ---- Print Name %, , Sf?
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 % C 1C1 System Mfg - Model #
Hoods_ Dimension(s)
f
Al
Plenums Dimensions(s) / CIGStan V -Bank
Ducts_ Dimensions(s)
Fuel /Heat Shut Off: Gas # %t> Electrical # Integral Make Up Air Shut Down 4Yes0 No
Cylinder Size(s) &Qty r Last Hydrostatic Test Date(s) Flow Points: Capacity Used
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
1 2 2 ?U
5
7 8
FIXED TEMPERATURE - SENSING ELEMENTS (SUCH AS FUSIBLE LINKS)
QTY TEMP MFG DATE INSTALL DATE QTY TEMP MFG DATE INSTALL DATE
State Ciro 1 aFshal ACC 2n Test Form 1012010
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Inspectiot ',T, _ ting, and Maintenance 0 Page 2 of
Wet Chi are -En ineered Fire Extinguishing S `stems - Title 19 Chapter 5 § 904.7
Property Address 1
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Date: -3
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System Location : a/' 6) System of
Contractor Name: JORGENSEN COMPANY
Item Frequency Description NFPA 17A Fail N/A Pass
unless noted)
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)
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
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 -1.1 through 1 -1.8)
M -1.2 Semi Annuallyy ll Agent Containers within Acceptable Hydrostatic Test 7.5.1 1ODates
M -1.3 Semi Annually All Auxiliary Pressure Containers and /or Hose Assemblies : 7.5.1(2)(3) Within Acceptable Hydrostatic Test Dates
M -1.4 Semi Annually Cartridge Weights within Acceptable Limits 7.3.2.1(2)
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)
M -1.8 Semi Annually Nozzles are Correct, Clean & Properly Aimed 7.3.2.1(2)
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) Correctly
M-2.1 6 Year Internal Maintenance as Required by the Manufacturer CCR T -19 904.7
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 applicable,standardds (T -19 §964_7)
FAIL Te nlclan Signature Date & Time of Service Cus4mer Acknowledgement
State G„-o MaFshai AES 20 Test Form 1012010