Permit CHECK SHEET FOR TEST OF FIRE EXTINGUISHING SYSTEMS AS REQUIRED) IN U.F.C. ` �, ,
Oregon
Date ?- .3 - l •
REPORT TO 1 �. Grl�f L C(3.G 5
te PHONE No.
Owner /Manager •
NAME OF BUILDING /V e u j ('o r R,4
ADDRESS OF BUILDING q4;79' S. (.4J ws► SA .. S 2 D i I' y ic-d
•
TYPE OF SYSTEMS BEING TESTED:
Dry Standpipe Wet Standpipe Dry Sprinkler System
K Wet Sprinkler System Combination Other
1. GENERAL
a. How many stories is the building? O. t Yes No Other
b. Is the building occupied? 1 I X
c. Are all the systems in service at time of test? X
d. Is the sprinkler system monitored by central station? I X
e. Are there tamper switches on all control valves? ; X.
f. What kind of fire protection systems are in this building?
Totally Sprinklered Partially sprinklered
Basement Sprinklers Only Exitway Sprinklers
Wet Standpipe Dry Standpipe 1 1. ALL SPRINKLER SYSTEM
•
,Yes No
a. Was the Fire Department connection check valve cleaned and /or A
back flushed from check valve to FDC?
b. Are all fire department connections in satisfactory x
condition, couplings free, caps and plugs in place?
c. What is the size of main drain? x
d. What was residual pressure when main drain was completely x
open? - 4
e. Was sprinkler system flushed from the control valve to
remote end of §prinkler system:
f. Was alarm bell•.6r motor gong checked and working by I
flowing water from inspector test?
g. Are all control valves open and in operating condition? `i( 1
h. Was anti- freeze solution in anti - freeze systems tested and •
the system left in satisfactory condition? I x
i. Is the sprinkler system, heads, piping, valves,
hangers and gages in satisfactory condition?
3. DRY SPRINKLER.SYSTEMS. •
a. What is the size of dry sprinkler valve ?• .
b. What is size of orifice on inspector test valve?
c. What was _ •. the • time for water to reach the' inspector: ` : ;:.: -' es 146:.";
test? :,ti.. I_ . •• . , � } , =•,..,-
d. Is dry valve in service and in good condition? • •- ; •.I ..•i ' i .•: •i: J
• •
Rev. 4/89
4. WET STANDPIPE
Yes No Other
a. What was residual PSI at the top of riser with 35 GPM
flowing?
b. How many hose stations on this system? 1
c. What are the fire hose sizes?
d. Are all the fire hoses, nozzles, valves and gaskets in
good working condition?
e. Do all hose valves and hoses have National Standard
threads?
f. Are all hangers and braces fastened?
5. DRY STANDPIPES
a. How many standpipes are on this building?
b. What is the size of the dry standpipe?
c. Were all outlet valves on the dry standpipe opened and
closed to determine that they function properly?
Are all hangers and braces fastened to building?
d. Was the dry standpipe tested with air pressure of 25 PSI
or more?
e. Was the dry standpipe hydrostatically tested with at
least 125 PSI?
Results of Test: Passed. Failed.
f. Was a flow test of 100 GPM of water flowed through the
standpipe to the roof?
g. Were all standpipes drained, caps replaced, and restored
to working condition at end of test?
6. COMBINATION SYSTEMS
.a. With 500 GPM flowing at highest outlet, what was the PSI
at the outlet?
7. FIRE PUMPS (Run at least 10 minutes)
a. What is the make, model, and the GPM rating of the fire
pump?
b. When roof valve was opened, did the fire pump come on
automatically?
e. Was the fire pump running at 100€ of capacity?
d. What was the pressure at the highest outlet when pump
was running?
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8. TANKS
a. Are all gravity and pressure tanks in good working con-
dition with the automatic filling system operational? •
9. EXPLAIN:
SS'STef/Y1 PA i • a 1- 1-►oPP�'ti 144.4-11 6 �ST�44
L /r`Su rA—/ s ` YiSP /3,v► . 1
Signature of certified personnel conducting test ./ /4 4,Z , /
NAME OF COMPANY DISCOUNTFIRESYST M _ PHONE (503 )777-5q0
402 S.E. JOHNSON CREEK BLVD.
24 HOUR NOTICE MUST BE BERMANDJOREGIDNIN2OTEST FOR WITNESSING. CONTACT THE FIRE MARSHAL'S
OFFICE,