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Home My WebLink About1000 REAL RoadInspection, Testing, and Maintenance A€S20 Page 1 of Wet Chemical Pre - Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7 Property Information: Name: U1 Address: t(�v ri�� 1L JORGENSEN COMPANY City: K_ t k. 2691 South East Ave. System Fresno, CA 93706 of �) ZIP: ��?� 9 C16 Lic. # 262995 Contact: IM�� A&'F_ TZ / f' Service Location: ,-z Telephone: �2 6J , % Date: J "yy ❑ 2691 S. East Ave Fresno 800 - 481 -3473 Copy sent to: ❑ 1536 Princeton Modesto 800 - 606 -0835 MPASS ❑ Owner Date ❑ 2345 S. Fruitvale Bakersfield 877 - 238 -6305 El El Fire AHJ Date ❑ 3190 Luyung Dr Rancho Cordova 800 - 758 -1124 FAIL Service Technician ! / ��"'7- Owner /Occupant 1 "I GI I� ; :t;t " J. �._ ` - L � Print Name ?� <<J� � \�\ i TF`I�� Print Name (' �()\1QY2,vlr f NOTES inspection, testing, and maintenance requirements and information, see California Code of Regulations, Title 19, 2 t--1L E1)Forpspecific Division 1, Chapter 5, §901 to §906 ion items may be performed by the property owner in accordance with CCR Title 19, Division 1, Chapter 5 §904.7 System Location s 1� �i ( f ; f 14CQ.) System Mfg A A RUC. Model # (C ' fG . #:Hoods ` Dimension(s) > #'Plenums Dimensions(s) A- Standard ❑ V -Bank # Ducts Dimensions(s) Res Fuel /Heat Shut Off: Gas # Electrical' # Integral Make Up Air Shut Down ❑ No Cylinder Size(s) & Qty �. y� 1 Last Hydrostatic Test Date(s) �W Flow Points: Capacity 1 I Used 0 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 Type Qty 1 3� 2 t--1L I fL 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 State biro Marshal ACC 20 Test Form 1012010 Inspection, Testing, and Maintenance AES20 Page 2 of l_ Wet Chemical Pre-Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7 Property Address: System Location A7 G F (AGGt> Contractor Name: JORGENSEN COMPANY Date: System ? of 3 Item Frequency Description NFPA 17A (unless noted) Fail N/A Pass -1.1 Monthly Manual Actuators are Unobstructed (i.e. i.e. remote pull station 72(2) V 1 -1.2 Monthly Tamper Indicators and Seals Intact 7.2.2(3) AF System Inspected, tested ana T pintained n accordance with m(anufa turer's written instructions and app1lic Jle standards (T -19 §904.7) ❑� PASS E � ��-'� JCI ` G jZ -CG A,4— ❑ FAIL Technician Signature Date & Time of Service Custom r ""nowledgement ' 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 V -1.8 Monthly Hood, Ducts & Protected Cooking Appliances Have Not Been Replaced Modified or Relocated 7 2 2(8) 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 Annual) Annually All Agent Containers within Acceptable Hydrostatic Test Dates 7.5.1 1 ( ) M -1.3 Semi Annually All Auxiliary Pressure Containers and /or Hose Assemblies Within Acceptable Hydrostatic Test Dates 7.5.1(2)(3) 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) V� ;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) y� M -1.8 Semi Annually Nozzles are Correct, Clean & Properly Aimed 7.3.2.1(2) 1 M -1.9 Semi Annually Fixed Temperature Sensing Elements Maintained or Replaced CFC 514.2.2 M -2.0 Semi Annuall y Auxiliary Equipment Such as Water Valves Functioned Correctly 7.3.2.1 2 :> ( ) V/ 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: AF System Inspected, tested ana T pintained n accordance with m(anufa turer's written instructions and app1lic Jle standards (T -19 §904.7) ❑� PASS E � ��-'� JCI ` G jZ -CG A,4— ❑ FAIL Technician Signature Date & Time of Service Custom r ""nowledgement • �ssr_�yrr_�,T,tzrsa:��•ti•�• • Inspection,_ Testing, and Maintenance A€520 Page 1 of _7 Wet'Chemical Pre - Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7 Property Information: Nozzle Qty Appliance Name Name: Nozzle Type Nozzle Qty Address: �C,C� �� -�- f1L �` �� JORGENSEN COMPANY z`( City: 1 �,,,Y_V !f ST ( I LL) 2691 South East Ave. System ZIP: �1`�Cj Fresno, CA 93706 ofj C16 Lie. # 262995 Contact: --7 Telephone: J? i _ G -� / Service Location: Date: I i El 2691 S. East Ave Fresno 800 - 481 -3473 ❑ 1536 Princeton Modesto 800 - 606 -0835 EP Copy sent to: ❑ Owner Date ❑ 2345 S. Fruitvale Bakersfield 877 - 238 -6305 PASS E] Fire AHJ Date El 3190 Luyung Dr Rancho Cordova 800 -758 -1124 FAIL `i Service Technician i Owner /Occupant to C'4 P r� Print Name 1, � � �. � l 7 (�VG► f/►1�►� �t?Ajv\��, l am` 4FC Print Name f f GCCU 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 w C�i- kGO) System Mfg A NSU(. Model # -- LEF;r c # Hoods , Dimension(s) z � # Plenums ! Dimensions(s) 03tandard ❑ V -Bank # Ducts Dimensions(s) ``(; k t Fuel /Heat Shut Off: Gas # ' Electrical # I Integral Make Up Air Shut Down 9Yes ❑ No Cylinder Size(s) &Qty 4; -( �� Last Hydrostatic Test Date(s) ", ( 66 ( 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 Z. z`( ( 2 Z Z�� J 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 State F=qFe Marshal A €S 29 Test Form 1012010 Inspection, Testing, and Maintenance AE-S20 Page 2 of 7 Wet Chemical Pre-Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7 Property Address: 1CJCG h V ' \L `. LE F T Date: System Location: C)k: i�C �� System Z of Contractor Name: JORGENSEN COMPANY Item Frequency Description NFPA 17A (unless noted) Fail N/A Pass 1 -1.1 Monthly Manual Actuators are Unobstructed 7 2 2(2) V 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 V M -1.1 Semi Annually Complete All Inspection Items (1 -1.1 through 1 -1.8) V , M -1.2 Semi Annually y ll Agent Containers within Acceptable Hydrostatic Test 7.5.1 1 ( ) V Dates 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) � j M -1.5 Semi Annually Liquid Level Within Acceptable Limits (Non- Pressurized) 7.3.2.1(2) V " 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 Annually Fixed Temperature Sensing Elements Maintained or CFC'514.2.2 Replaced M -2.0 Semi Annually y uxiliary 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: r h System Inspected, tes4ed and maintained in accordance with manufa turer's written instructions and applicabl standards (T -19 §904.7) As ❑ FAIL Technician Signature Date & Time of Service Custo er Acknowledgement State G•.o nn.,,-shal F=8 20 Test Form 1012010 Inspection, Testing, and Maintenance A€S20 Pagel of L. Wet Chemical Pre - Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7 Property Information: Name: ��C 1y�L��S Address: \�CjCXj JORGENSEN COMPANY City: C�tP\ '�(_1 2 (,._ D 2691 South East Ave. System C ' Fresno, CA 93706 of ZIP: ` i9 C16 Lic. # 262995 Contact: tik N— C -t lQ_ ( Service Location: Telephone: (� 2 f ` - G j � �% Date: - ❑ 2691 S. East Ave Fresno 800 - 481 -3473 Copy sent to: ❑ 1536 Princeton Modesto 800 - 606 -0835 ❑ Owner Date El 2345 S. Fruitvale Bakersfield 877 - 238 -6305 PASS ❑ Fire AHJ Date ❑ 3190 Luyung Dr Rancho Cordova 800 - 758 -1124 FAIL T "� �' ❑ Service Technician fi Owner /Occupant ( h (, +��Pl/ Print Name N TKI, Print Name j V1r7i �� rcl NOTES 1) For specific inspection, testing, and maintenance requirements and information, see California Code of Regulations, Title 19, 4 J Division 1, Chapter 5, §901 to §906 2) Inspection items maybe performed by the property owner in accordance with CCR Title 19, Division 1, Chapter 5 §904.7 System Location \G�i\ 1 L r System Mfg A NSOIL- Model # c # Hoods Dimension(s). ` # Plenums Dimensions(s) LiStandard ❑ V -Bank , YL� ` #;Ducts Dimensions(s) Fuel /Heat'Shut Off: Gas # ' Electrical # Integral Make Up Air Shut Down N,Yes ❑ No Cylinder,Si e(s) & Qty _ZS- dX (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 -Z L5_-/1 3 4 J 5 6 7 8 FIXED TEMPERATURE - SENSING ELEMENTS (SUCH AS FUSIBLE LINKS) QTY TEMP MFG DATE INSTALL DATE QTY TEMP MFG DATE INSTALL DATE -Z L5_-/1 State Fore Marshal AES 20 Test Form 1012010 Inspection, Testing, and Maintenance AES2 A Page 2 of Wet Chemical Pre-Engineered Fire Extinguishing Systems - Title 19 Chapter 5 § 904.7 1 CCG lz�_ A l V-70 Property Address: t /((3 Date: VC r �G _ System Location 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) j i.e. remote pull station �J 1 -1.2 Monthly Tamper Indicators and Seals Intact 7.2.2(3) v 1 -1.3 Monthly Maintenance Tag in Place CCR T -19 906 V� 1 -1.4 Monthly No Obvious Physical Damage 7.2.2(5) v 1 -1.5 Monthly Gauge Readings within Proper Limits (Stored Pressure) 7.2.2(6) I/ 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 t/ 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 V 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 j T -1.4 Annually Regulator Tested and is Within Acceptable Limits 7.3.2.3 V 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 Annually Semi Annual) All Agent Containers within Acceptable Hydrostatic Test 7.5.1 1 ( ) Dates 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 Annuall y Fixed Temperature Sensing Elements Maintained or CFC 514.2.2 V Replaced M -2.0 Semi Annuall y Auxiliary Equipment Such as Water Valves Functioned 7,3.2.1 2 ( ) Correct) M -2.1 6 Year Internal Maintenance as Required by the Manufacturer CCR T -19 904.7 i/ 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: r System Inspected; tested and maintained in accordance with manufacturer's written instructions and app(icatile,standards- (f19 §904.7) 0� PASS I` ' ° �� 1 Z!Jl (G 17 'CC' `� � ❑ FAIL Technician Signature Date & Time of Service Cu" t me(Acknowledgement e+ - +o G„-o MaFshal AES 20 Test Form 1012010