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HomeMy WebLinkAboutIND/GAS SYSTEMS REP. 3/15/11Simp/exGrinne // BE SAFE. INDUSTRIAL /GAS STATION SYSTEMS REPORT 27th 4U. � u Av�rtua f:�4,'9 FGesm CA 93727 1IC.0 8ME01 P M9- 1118_C W F 65&W _M1 " � J Customer MX0(_'t Pr L h r N f�`.v -- i .I - Address 5� ihr, k. ('.I, CA- `? 3 ?Z%t Attention Phone (�nti1 ) �i k 67 Fax ( ) 1. Panel operation normal (if applicable) 2. Check batteries _(if applicable) 3. Check position of all nozzles 4. System installed per MFG. UL listing " 5. Check if seals intact evidence of tampering 6. If system has been discharged, report same ' 7. Pressure gauge in proper range (if gauged) 8. Check cartridge /actuation cylinder weight �� Z,> 0 9. Hydrostatic /Six Year maintenance date �_o 1 o 10. CCTV system (Gas Station Only) (Yes or No) 11. Inspect cylinder & mount 12. Test remote pull station 13. Test abort (if applicable) 14. Test detection 15. Check time delay (if any) 16. Verify operation of shutoffs /microswitches Date of Service Time F PM L 18. Simp/exGrinne // BE SAFE. INDUSTRIAL /GAS STATION SYSTEMS REPORT 27th 4U. � u Av�rtua f:�4,'9 FGesm CA 93727 1IC.0 8ME01 P M9- 1118_C W F 65&W _M1 " � J Customer MX0(_'t Pr L h r N f�`.v -- i .I - Address 5� ihr, k. ('.I, CA- `? 3 ?Z%t Attention Phone (�nti1 ) �i k 67 Fax ( ) 1. Panel operation normal (if applicable) 2. Check batteries _(if applicable) 3. Check position of all nozzles 4. System installed per MFG. UL listing " 5. Check if seals intact evidence of tampering 6. If system has been discharged, report same ' 7. Pressure gauge in proper range (if gauged) 8. Check cartridge /actuation cylinder weight �� Z,> 0 9. Hydrostatic /Six Year maintenance date �_o 1 o 10. CCTV system (Gas Station Only) (Yes or No) 11. Inspect cylinder & mount 12. Test remote pull station 13. Test abort (if applicable) 14. Test detection 15. Check time delay (if any) 16. Verify operation of shutoffs /microswitches Date of Service Time AM PM o A. 18. Clean detectors � I� I Annual Semi- Annual Recharge Installation Renovation Other Replace detection (if applicable) Ots.. +1iI a I Check travel of cable nuts /s -hooks c Location of Cylinders j_ '• # of Cylinders t.Cfw? taro+ e'er !� �i i f (� 'C� 1 ird�n'ir if`0 � r Mantifacturer Model Clean Agent Dry Chemical �C� C S'.o 24. Manual and remote set/seals in place A C . Cylinder Size (Master) j Cylinder Size (Slave) Cylinder Size (Slave) Fusible Links Thermal etection __,Smoke Dejection , Other Qty Temp. � Qty. Temp. 27. Slave system operational •: 28. Clean cylinder &mount ' Fuel Shut Off Electric Shut Off Fire Alarm Tie In Other t yr != 30. Personnel instructed in proper operation I 31. Proper portable extinguisher Panel Type Aattery Size Abort Time Delay der Wei is /Size � Cylinder Last Cylin�der Test Date(s) + `System ID# Technician Lic. # S iTA 17. Clean nozzles C % o A. 18. Clean detectors � I� I N S 19. Check sensitivity of detectors ! {�' Ifu _ 20. Replace detection (if applicable) Ots.. +1iI a 21. Check travel of cable nuts /s -hooks c 1 A/ ter 22. Piping and conduit securely bracketed if`0 � r V t 23. Shutoff reset 4- �� 24. Manual and remote set/seals in place Ol IF'c 1 b�S 25. Replace system covers 26. System operational 27. Slave system operational �! 28. Clean cylinder &mount 'yd o N 29. Proper warning sign t yr != 30. Personnel instructed in proper operation I 31. Proper portable extinguisher 32. Service and certification tag on system NOTE DISCREPANCIES OR DEFICIENCIES �n i� P+r� T/1,• 1 ');A a i• 1 /i 0 J21`r .,A 14i C_ Y CI!'! 'r,V -'- C, r s/t r" t'f ! t1JV: G A! 11 tQ 4 � 10.f IMPORTANT NOTICE TO CUSTOMER Customer acknowledges and agrees to the terms and conditions on the reverse side of this Industrial /Gas Station Systems Report, agrees that the services have been completed to Customer's satisfaction and that the system is in good working order and repair, unless services performed were of a temporary nature, in which case Customer acknowledges that part of customer's system may have been bypassed or is otherwise inoperable until service can be completed. CUSTOMER'S ATTENTION IS DIRECTED TO THE LIMI- TATION OF LIABILITY, WARRANTY, INDEMNITY AND OTHER CONDITIONS ON THE REVERSE SIDE. Acceptance of customer or customer's representative W TOTAL SERVICE Date Time �5. TOTAL SALES Cuswmeff's�Authorized Agent LABOR or FRT or � I� I TRIP CHARGE /� % TAX ON TOTAL � .fs- � -::.�. i�vl SALES GRAND TOTAL - S rice Technician • Date Time AM PM Cuswmeff's�Authorized Agent ft ,9! -r1r o r�'Y:� /. ,n•r w � I� I f i�, t /� � .fs- � -::.�. i�vl L17 SG0796 (08 /07) - © SimplexGrinnell LP 2007. All Rights Reserved TECHNICIAN COPY