16200 SW PACIFIC HIGHWAY-3 o�
ADDRESS:
i Areco rds\mic rof IrTA'argets\building.doc
FORM 10-21 (REV 8/91)
SHEET 1 OF 1 (PRESS FIRMLY YOU ARE MAKING FIVE COPIES)
REPORT OF INSPECTION
BY "AUTOMATIC" SPRINKLER CORPORATION OF AMERICA
FIRE PROTECTION SERVICES
Inspection Repot A FIGGIE INTERNATIONAL COMPANY
inspo tion ontract
PROTECTION SYSTEM
No. . . . . . . . . RANGE HOOD FIRE
Conferred with(Customer)
Codo
No
Please Print NameSig lure
REPORT 70 ILA
BUILDING OR LOCATION
STREET_ C�'�-^ �TECHNICIAN
CITY 8 STATE PHONE _����S r DATE
1.TYPE OF SYSTEMS LL !� 1
A SYSTEM N1 MANUFACTURER T� •y, MODEL/SIZE ( �
SYSTEM 02 MANUFACTURER
-- --------_--_. MODEL/SIZE
SYSTEM 03 MANUFACTURER_ _ MODEL1SIZE ---
B. EXTINGUISHING AGENT ( )ABC DRY CHEMICAL I J KARBALOY
""t4l BC DRY CHEMICAL ( J CARBON DIOXIDE
C. CYLINDER SER. NO. �`� I j PRESSURE/WEIGHT A+ �� `7
HYDROSTATIC TEST DATE_ r
CYLINDER SER. N0.. �� ` t- PRESSURE/WEIGHT
,�
_ �- __ HYDROSTATIC TEST DATE_
CYLINDER SER. NO._ PRESSURE/WEIGHT_ HYDROSTATIC TESL :)ATE ,
CYLINDER SER.NO. PRESSURE/WEIGHT HYDROSTATIC. 'EST
CYLINDER SER. NO. PRESSUREIWEIGHT HYDROSTATIC TEST DATE
CYLINDER SER NO._ _ _ PRESSUREIWEIGHT _ HYDROSTATIC TEST DATE
2. CONDITION ON ARRIVAL YES N/A NO
A. ARE ALL TAGS, SEALS AND CONTROL HEADS IN PROPER POSITION?
R ARE ALL SYSTEMS IN SERVICE AND AREAS PROPERLY PROTECTED?
3. SYSTEM INSPECTION OR TEST
A. ARE THE CONDITION OF ALL DUCT AND PLENUM AREAS IN
SATISFACTORY CONDITION,N07ZLE AND PIPING FREE OF
OBSTRUCTIONS AND At A PROPER DISTANCE FROM THE HAZARD?
S. ARE DETECTORS AND/OR FUSIBLE LINKS IN GOOD CONDITION
AND PROPER RATING FOR HAZARD?
IF CHANG , E.NTEP()f AFipF fANUFACTURING,T,YP N MAKE
C. WAS GAS OR ELECTRIC SHUT OFF AND
MANUAL PULL STATIONS
1 TESTED AND DID THEY OPERATE PROPERLY? . . . . . . . . .
0. WAS SYSTEM RESTORED TO SERVICE?
E. ALL LOCAL AND SUPERVISORY FEATURES TESTED AND SATISFACTORY? v
r. ALL SYSTEMS WERE TESTED AND FOUND TO BE FUNCTIONING
PROPERLY A1'THIS TIME? . . . . . .
4. EXPLANATION OF"NO"ANSWERS.
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