Report (91) C/ 'Zo/C - f cJ
Contractors Material and Test Certificate for Aboveground Pip
g
PROCEDURE
Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative.
All defects shall be corrected and system left in service before contractor's personnel finally leave the job.
A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and
contractor. It is understood the owner's representative's signature in no way prejudices any claim against contractor for faulty material,
poor workmanship,or failure to comply with approving authority's requirements or local ordinances.
PROPERTY NAME: 1351\-\- C s ■
PROPERTY ADDRESS: / IN 04.2 . X _ , dr, . , 4. 1 DATE: )jS—/?
ACCEPTED BY APPROVING AUTHORITIES(NAMES) o T/1 4 r /
PLANS per- iqn O�
ADDRESS 13 rx 5l i...10 k' C3\\.17 °.i-;•,ty f`e\ O 9 )-D..3:4-3
INSTALLATION CONFORMS TO ACCEPTED PLANS KYES 0 NO
EQUIPMENT USED IS APPROVED x YES 0 NO
IF NO,EXPLAIN DEVIATIONS.
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS ®YES 0 NO
TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANCE
IF NO,EXPLAIN
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES?
1.SYSTEM COMPONENTS INSTRUCTIONS YES54 0 NO
2.CARE AND MAINTENANCE INSTRUCTIONS YES0 NO
3.NFPA 25 I i YES 0 NO
LOCATION SUPPLIES BUILDINGS
OF SYSTEM
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL
MODEL MANUFACTURE SIZE QUANTITY RATING
*T
SPRINKLERS . 1 •+v.)t C: 3j' A 0tool O C7 -
OP
.Nt TY-21-1i a() I ir ) 1 ' ri°
Jic lh( v31t/0 t( I1 -S'3 155°
PIPE AND TYPE OF PIPE C,9-1);,(' t . c. 1O .i-- 9 0
FITTINGS TYPE OF FITTINGS C .' U•( t C.-re c V---"K
ALARM MAXIMUM TIME TO OPERATE
ALARM DEVICE THROUGH TEST CONNECTION
VALVE
OR FLOW TYPE. MAKE. MODEJ. MN SEC
INDICATOR
na Wi•.
,5(h. (-713
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
UltC c ltc WM.-IV-t5
TIME TO TRIP TIME WATER ALARM
THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
DRY PIPE CONECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY
OPERATING MIN SEC PSIPSI PSI MIN S YES NO
TEST WITHOUT �
O.O.D. ® 0 v
WITH
QOD.
IF NO,EXPLAIN
•
OPERATION 0 PNEUMATIC 0 ELECTRIC 0 HYDRALIC
DELUG •
PREACTION • '‘ SUPERVISED 0 YES 0 NO DETECTING MEDIA SUPERVISED ■ YES 0 NO
VALVES
DOES VALVE OP '.- % •OM THE MANUAL TRIP,REMOTE,OR BOTH 0 YES 0 NO
CONTROL STATIONS
IS THERE AN ACCESSIBLE FACILITY IN EA - ,I',0 IF NO,EXPLAIN
FOR TESTING 0 YES 0 NO
s 0 •CH CIRCUIT OPERATE DOES E• r CUIT MAXIMUM TIME TO
MAKE M•• SUPERVISION LOSS ALARM? OPERATE VALV • ._ •SE OPERATE RELEASE
YES NO YES NO MIN SEC
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•
LOCATION MAKE& SETTING STATIC PRESSURE RESIDUAL A�G
REDUCING URE FLOW RATE
PRESSURE &FLOOR MODEL LET(PSI) OUTLET(PSI) INLET(PSI)(OUTLET(PSI) FLOW(GPM)
VALVE TEST
ROSTATIC: drostatic tests shall be made at not less than 200 PSI(13.6 bars)for 2 hours or 50 PSI(3.4 bars)
TEST ` a sure in excess of 150 PSI(10.2 bars)for 2 hours. Differential dry-pipe valve clappers shall be left
DESCRIPTION open during the test to prevent damage. All aboveground leakage shall be stopped.
PNEUMATIC:Establish 40 PSI(2.7 bars)air pressure and measure drop,which shall not exceed 11/2 PSI(0.1 bars)
In 24 hours. Test pressure tanks at normal water level and air pressure and measure air pressure drop,which shall
not exceed 1'%PSI(0.1 bars)in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT __RIF NO,STATE REASONV SI_BARS FOR Z.—HRS
DRY PIPING PNEUMATICALLY TESTED '1 YES 0 NO
EQUIPMENT OPERATES PROPERLY •. YES 0 NO
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS,
SODIUM SILICATE OR DERIVITIVES OF SODIUM SILICATE,BRINE,OR OTHER CORROSIVE CHEMICALS
WE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
YES 0 NO
TESTS TESTSUPPLYSSUP�IYGTESF CONNECTION '67 PSR( BARS) ONNECTIONOPEN�WIDE 1PSI TESTBARS)
WATER RESIDUAL INUNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE
CONNECTION MADE TO SPRINKLER PIPING
VERIFIED BY COPY OF THE U FORM NO.85B YES 0 NO
OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER- YES 0 NO
GROUND SPRINKLER PIPING
IF POWDER-DRIVEN FASTENERS ARE USED IN 0 YES 0 NO
IF NO,EXPLAIN
CONCRETE,HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED? NUMBER REMOVED
BLANK TESTING NUMBER USED I LOCATIONS
GASKETS •
WELDED PIPING IQ YES 0 NO
IF YES....
AT
PDO YOU CERTIFY AS ROCEDURES OMPLY;E WITH THE LREQUIREMENTS OLER CONTRACTOR F AT LEAST WELDING YES 0 NO
AWS D10.9,LEVEL AR-3?
YES 0 NO
WELDING Q ALCERTIFYOU D IN OMPL COTHAT MPLIANCE WITH THE REQUIREMENWELDING WAS TS OF AT LEASTD BY RS
AWS D10.9,LEVEL AR-3?
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE
WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE YES 0 NO
THAT ALL DISCS ARE RETRIEVED,THAT OPENINGS IN PIPING ARE
SMOOTH,THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED,
AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED? YES 0 NO
T YOU
A CONTROL
(DISCS)
CUTOUTS DO YOU CERTIFY ENSURE THATALL CAUTOUTS HAVE
AREERETRIEVED? TO
HYDRAULIC NAMEPLATE PROVIDED I IF NO,EXPLAIN
DATA k YES 0 NO
NAMEPLATE
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS -
NAME OF SPR( KLER COONNTRACTO
Vito\-c_cro
TEST TITLE DATE
WITNESSED FOR PROPERTY OWNER(SIGNED)
BY
FOR SP r i ER CONA OR(SIGNED) TITLE DATE
,,, �-V\ ` 7
ADDITIONA E 'LANATIOrR► NO
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