Report i p 730 6' m/ /30 r ,, vE_.
re526//b' —�1/
. .
To be Completed by Re.enal Office
Job Name , Ales 1 -e Ea 4'6 / Ciar vrc Job Number
Job Address /2 5 i2W 5c/, a ter V Type of System: Ansul X
7 Of 1 71 23 • Pyrochem O
Other
To be Completed by Fire System Distributor
G
Company Name ?..4 . F/r� b ¢ecta oz System Model if-1/1-sv . L-
r
Address /01.2 5 W A Ave, Serial Number i —! d
c cfva / /i5, O, £17. 33
Fuel/Energy Shut Off Device Gas Valve: Mechanical, BectriOal ❑ Sias.
installed. Tested on 3 / 2 3/// Electric Equipment Shut-down Tested: , Yes DNo
Date
This Fire Suppression System is installed in accordance with the Manufacturer's instructions and
drawings, NFPA Wind 17 (current issues) and eh applicable state and local codes. All electrical
work or work performed by others to complete the Installation of this system has been completed.
Exceptions to the above are noted below (Use back of sheet if necessary)
Installer's Nam (a-I, e � , /k a » y 4
Signature, _ Date, 'mar, a 3 ao//
To be Completed by tamer or Net's Reprosonitatitre
I have received a copy of the Fie Suppaversion System Owner's Manual and I understand it. I also
understand that it is the recommendation of the National Fire Protection Association (NEPA),that
the system be inspected every six months to maintain its reliability.
Signature 6A re-.� , , , , CO ;An--, Date , -- 2 Z3 - l
•
To be Camp by Authority Having Ju
Functional vv�essed and the performs as designed.
Signature Dem 2 j ` l
■