Report (98) \ -4 Q 1
Contractor's Material and Test Certificate for Aboveground Piping
PROCEDURE' Z /s— c V t 7c
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: V(,f T r f 4 Ec 'E By/.'Ad; d l
PROPERTY ADDRESS: /?a 7 7 <M/ 41, �/t , 01? 7?ea DATE:I,—Ii'""/r
ACCEPTED BY APPROVING AUTHORITIES(NAMES) /•
PLANS /• r iv " ?,, s-rA
ADDRESS
INSTALLATION CONFORMS TO ACCEPTED PLANS ErYES 0 NO
EQUIPMENT USED IS APPROVED EYES 0 NO
IF NO,EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS ETYES 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 ' YES 0 NO
2.CARE AND MAINTENANCE INSTRUCTIONS YES 0 NO
3.NFPA 25 t]/YES 0 NO
LOCATION SUPPLIES BUILDINGS
OF SYSTEM Ali
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QUANTITY RATING
ii:[a yuC VL7 z•L sit Z {r s
SPRINKLERS V C.I .t.0 V3 •ulb 16 1Z. t� I 2 Zoe
v.c.p I ( v t7 It!- LOX v 2 3 /SS
PIPE AND TYPE OF PIPE GPVi, Ste q elk
FITTINGS TYPE OF FITTINGS PV( I
MAXIMUM TIME TO OPERATE
ALARM ALARM DEVICE THROUGH TEST CONNECTION
VALVE
OR FLOW TYPE. MAKE. MODE! MIN SFC
INDICATOR PWiftA%
OW Sw.iCK SCASfr VS'f 61 0 3 5
DRY VALVE Q.O.D.
•� MODEL SERIAL NO. M' MODEL SERIAL NO.
I •. 0 TRIP TIME WATER ALARM
THROU - ST WATER AIR TRIP POINT REACHED OPERATED
DRY PIPE CONECTIO N PRESSURE P' -: AIR PRESSURE TEST OUTLET PROPERLY
OPERATING MIN SEC PSI PSI PSI MIN SEC YES NO
TEST WITHOUT
O.O.D.
WITH
Q.O.D. ,
IFNO,EXP 4I
OPERATI• 0 PNEUMATIC 0 ELECTRIC ■ HYDRALIC
DELUGE AND
PREACTION PIPING SUPERVIS . 0 YES 0 NO DE • I G MEDIA SUPERVISED 0 YES 0 NO
VALVES
DOES VALVE OPERATE FR• MANUAL TRIP,RE o: ,OR BOTH 0 YES 0 NO
CONTROL STATIONS
IS THERE AN ACCESSIBLE FACILITY IN > • CIRCUIT IF NO,EXPLAIN
FOR TESTING 0 YES 0 Ni
DOE ''CH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL 'VISION LOSS ALARM? :' RATE VALVE RELEASE OPERATE RELEASE
YES NO . NO MIN SEC
Page 1 of 2
LOCATION MAKE& SE •1 G STATIC ''. SURE RESIDUAL PRESSURE FLOW RATE
PRESSURE &FLOOR MODEL (FLOWING)
REDUCING 1 T(PSI) OUTLET(PSI) INLET(PSI) OUTLET(PSI) FLOW(GPM)
VALVE TEST
HYDROSTATIC:Hydrostatic tests shall be made at not less than 200 PSI(13.6 bars)for 2 hours or 50 PSI(3.4 bars)
TEST above static pressure 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 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 11/2 PSI(0.1 bars)in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 7!6-PSI BARS FOR 2. HRS IF NO,STATE REASON
DRY PIPING PNEUMATICALLY TESTED LI YES 0 NO N ak
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
WERE NOT USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
iT,YES 0 NO
TESTS DRAIN READING OF GUAGE LOCATED NEAR WATER RESIDUAL PRESSURE WITH VALVE TEST IN
TEST SUPPLY TEST CONNECTION:I I PSI ( BARS) CONNECTION OPEN WIDE:LOOP 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 tit YES 0 NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING YES 0 NO
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 LOCATIONS
GASKETS N„A
• WELDED PIPING 0 YES NO
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING 0 YES 0 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 ❑-YES 0 NO
QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST NA
AWS D10.9,LEVEL AR-3? 1TL1
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 0
SMOOTH,THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED,
AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED?
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO 0 YES 0 NO
(DISCS) ENSURE THAT ALL CUTOUTS(DISCS)ARE RETRIEVED?
HYDRAULIC NAMEPLATE PROVIDED �/ I IF NO,EXPLAIN
DATA M YES 0 NO
NAMEPLATE
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN r 2 L.4/
REMARKS rx,,
NAME OF SPRINKLER CONTRACTOR
5c-i clr-t {'tc4c-f;oi
TEST TITLE ATE
BWYTNESSED FO; ''0 •WNER(SIGNED)le � � - �q `g
Flo •.. • .CTOR(SIGNED) TITLE
(�DATE
/I 44e-ri .. Sft (7--tet y 1r-
ADDITIONAL
r-
ADDITIONAL EXPLANATION AND NOTES
Page 2 of 2