Report (117) rp5. ci?-
Contractor's Material and Test Certificate` for Aboveground`Piping}
PROCEDURE ` \ ,\K i k\Z L c''�� A
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: 1 e� SC-VNI, 1.15 ?DU-C.' UJBI3
PROPERTY ADDRESS: i 3 .4.1.3ao (�2
3� acdl 'T:Trd O' ci7C.CZDATE: `0- - 17
ACCEPTED BY APPROVING AUTHORITIES(NAMES) Cl C T-ct.{'A
PLANS ` � y
ADDRESS 13 a-6 '5it) A-4QL\ g jO 12p..CPT C 9-7 a` 3
INSTALLATION CONFORMS TO ACCEPTED PLANS `'! YES 0 NO
EQUIPMENT USED IS APPROVED 1G YES 0 NO
IF NO,EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS KYES ❑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 i YES ❑NO
2.CARE AND MAINTENANCE INSTRUCTIONS YES ❑NO
3.NFPA 25 YES ❑NO
LOCATION SUPPLIES BUILDINGS
OF SYSTEM
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QUANTITY RATING
U tNea\tC sj F40 °tv VLe k I a` -a5_s5
SPRINKLERS :1 TY i3 i '04:511.40iIa i5-i c�
i/�CLS,C, k.134,1(7 • DI'l i" 36
'0._e tAN)Lc KA i i.l04 n 'O t 7 I �
i o n
C: L ` a
CPIPE AND TYPE OF PIPE ,p• i- C 0-1).- �
. i -f S C,L-
FITTINGS TYPE OF FITTINGS ...t •J-C A
I 3c t 0 - t_ 0
MAXIMUM TIME TO OPERATE
ALARM ALARM DEVICE THROUGH TEST CONNECTION
VALVE
OR FLOW TYPE. MAKE. _ MODEI MIN SFC
INDICATORO 37
�0:„) tyy►G v6e
DRY VALVE d� Q.O.D.
MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO.
\)( 1t L. M kr ltzle5
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 PSI PSI PSI MIN SEC YES NO
TEST WITHOUT
O.O.D.
WITH
Q.O D.
IF NO,EXPLAIN
OPERATION CI PNEUMATIC 0 ELECTRIC El HYDRALIC //f
DELUG
PREACTION - . SUPERVISED El YES 0 NO DETECTING MEDIA SUPERVISED • YES 0 NO
VALVES
DOES VALVE OP • - r 'OM THE MANUAL TRIP,REMOTE,OR BOTH ❑ YES 0 NO
CONTROL STATIONS
IS THERE AN ACCESSIBLE FACILITY IN EA - —Pt"+ IF NO,EXPLAIN
FOR TESTING ❑ YES 0 NO
0 e- ACH CIRCUIT OPERATE DOES EA _ 1'CUIT MAXIMUM TIME TO
MAKE M•I' SUPERVISION LOSS ALARM? OPERATE VALVE ' _ ,SE OPERATE RELEASE
YES NO YES NO IN SEC
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LOCATION MAKE& SETTING STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE
PRESSURE &FLOOR MODEL (FLOWING)
REDUCING LET(PSI) OUTLET(PSI) INLET(PSI) OUTLET(PSI) FLOW(GPM)
VALVE TEST
DROSTATI ydrostatic tests shall be made at not less than 200 PSI(13.6 bars)for 2 hours or 50 PSI(3.4 bars)
TEST ; . ' . -ssure 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 Ph 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 1h PSI(0.1 bars)in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT' -CC1 SI BARS FOR HRS IF NO,STATE REASON
DRY PIPING PNEUMATICALLY TESTED a YES 0 NO
EQUIPMENT OPERATES PROPERLY 13 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 OT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
YES 0 NO
TESTS DRAIN READING OF GUAGE LOCATED NEAR WATER RESIDUAL PRESSURE WITH VALVE TEST IN
TEST SUPPLY TEST CONNECTION: PSI ( BARS) CONNECTION OPEN WIDE: PSI( BARS)
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE
CONNECTION MADE TO SPRINKLER PIPING
VERIFIED BY COPY OF THE U FORM NO.85B Pi YES 0 NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING K.YES 0 NO r
IF POWDER-DRIVEN FASTENERS ARE USED IN 0 YES ❑ NO IF NO,EXPLAIN
CONCRETE,HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED?
BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED
GASKETS
WELDED PIPING tk YES 0 NO
IF YES....
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING KYES ❑ NO
PROCEDURES COMPLY WITH THE REQUIREMENTS OF AT LEAST
AWS D10.9,LEVEL AR-3?
WELDING DO YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS r \YES 0 NO
QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST
AWS D10.9,LEVEL AR-3?
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE
WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE
THAT ALL DISCS ARE RETRIEVED,THAT OPENINGS IN PIPING ARE GI YES 0 NO
SMOOTH,THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED, y[
AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED?
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO irgqYES 0 NO
(DISCS) ENSURE THAT ALL CUTOUTS_(DISCS)ARE RETRIEVED?
HYDRAULIC NAMEPLATE PROVIDED IF NO,EXPLAIN
DATA YES ❑ NO
NAMEPLATE
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN
REMARKS -�
(0-x-`q
1-1`7
NAME OF SPRINKLER CONTRACTOR
TEST
WITNESSED F• PROPS TY OWNER(S GNED) TIT (T DATE
BY
FO .'' I — ONTRA CT (SIGNED) TITLE DATE
tWilL COre-VvkaNsiNs )1 13
ADDITIONAL EXPLA 0 •ND N I ES
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