Report CONTRACTOR'S MATERIAL & TEST C,ER CERTIFICATE FOR lit, )BOVEGROUND PIPING .
PROCEDURE
Upon completion c4 work. Inspedlon 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 lob.
A canificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and contractor. it is understood the owners rep-
resentative's signature In no way preludicas any Maim against contractor for faulty material, poor workmanship, or failure to comply wrth approving authority's requirements or
local ordinances.. .
PROPERTY NAME DATE
Tu•i4.4.Tra �j ! UAL L. F C& 4 E , 5 e..ctE 1.1, (o" -(O
PROPERTY ADDRESS f
1 19`1 5,w, 7e) s4uc, 164e-o O4, ° I72 . 2'.3
. • ACCEPTED BY AP ROVING %
AUTHORITIES {JAMES)
/?'"7'' E' f C. ,Q teo •
. ADDRESS
•
_ PLANS _ •
INSTALLATION CONFORMS TO ACCEPTED PLANS OYES ❑ NO
EQUIPMENT USED IS APPROVED OYES 0 NO •
IF NO, EXPLAIN DEVIATIONS •
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS T O LOCATION YES 0 NO
OF CONTROL VALVES AND CARE AND MAINTENANCE OF THIS NEW EQUIPMENT?
IF NO, EXPLAIN
•
•
INSTRUCTIONS
• HAVE COPIES OF THE. FOLLOWING BEEN LEFT ii ON THE PREMISES: C(YES 0 NO
1. SYSTEM COMPONENTS INSTRUCTIONS C.YES 0 NO
2. CARE AND MAINTENANCE INSTRUCTIONS !8' - YES' ❑ NO
3. NFPA-13A • Dt(i y m ❑ YES e.NO
LOCATION SUPPLIES BUILDINGS �( •
OF SYSTEM r�t - ("'mac- TI.0.3 SY - r - €1 , -- , o
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURE SEE QUANTITY RATING
V IC.TA aLie_ V 39 9,o q / .S
SPRINKLERS
�
VIe.,7 fe, It 3 8 5fc. /3-3-
`1'L.o I 77'-- Fg13 t/A I 5,4 y I /5.5
PIPE AND Type olPipe [>!-(, /0 1 .54.44, ri✓C) • �°
FITTINGS Typs of Fittings et" 1 r Utrl (.j /1 S Le s r,., C.Q
MAXIMUM TIME TO OPERATE
ALARM ALARM DEVICE THROUGH TEST CONNECTION
VALVE TYPE MAKE MODEL MIN. SEC.
CR FLOW
INDICATOR V sg - F rAm) PoTS,EEEic..._ ✓s/L - F 0 . L O
DRY VALVE Q.O.D.
MAKE MODEL SERIAL NO. I MAKE MODEL SERIAL NO.
i .. - . .
. TIME TO' T RIP TIME WATER - ALARM
THRU TEST WATER AIR TRIP POINT ' REACHED OPERATED
DRY PIPE CONNECTION' PRESSURE PRESSURE. AIR PRESSURE , TEST OUTLET' PROPERLY
OPERATING MIN. I SEC. I PSI ' PSI PSI MIN, I SEC. YES NO
TEST
Without .
O.O.D.
With
Q.O.D.
IF NO, EXPLAIN .
•
' MEASURED FROM TIME INSPECTORS TEST CONNECTION IS OPENED.
■
' OP ER ;O:♦
PNEUMATIC X ELECTRIC ❑ HYDRAULIC
PIPING SUPERVISED DYES ❑ NO I DETECTING MEDIA SUPERVISED yo,,YES ❑ NO
DOES VALVE OPERATE FROM I E MANUAL TRIP AND/OR REMOTE CONTROL STATIONS KYES ❑ NO
DELUGE & IS THERE AN ACCESSIBLE FACILITY IN EACH CIRCUIT FOR TESTING IF NO, EXPLAIN
PRE&CTEON -
VALVES $YES ❑ NO
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISION LOSS ALARM OPERATE VALVE RELEASE OPERATE RELEASE
YES NO YES I NO MIN. I SEC.
V l crA.uLlG 76 9
HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi (13.6 tzars) for two hours or 50 psi (3.4 bars) above static pressure in excess
of 150 psi (10.2 bars) for two hours. Differential dry -pike valve dapper shell be {at open during test to prevent damage. All aboveground piping leakage
TEST shal'be stopped. .
DESCRIPTION PNEUMATIC: Establish 40 2.7 bars) air pressure and measure drop which shall not deed 1 -1/2 psi (0.1 bars) in 24 hours. Test
Fs! ( )" P G� P ( ) pressure
P
tanks at norrrsl water a^vel and air pressure and measure air pressure dros which shall not exceed 1 -1/2 psi (0.1 bars) in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT ZOO PSI FOR Z HRS. IF NO, STATE REASON
DRY PIPING PNEUMATICALLY TESTED 12' YES ❑ NO .
EQUIPMENT OPERAS PROPERLY , YES ❑ NO
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS, SODIUM SILICATE OR
DERIVATIVES OF SODIUM SILICATE, BRINE, OR OTHER CORROSIVE CHEMICALS WERE NOT USED FOR TESTING SYSTEMS OR
TESTS STOPPING LEAKS? ,,, YES ❑ NO
DRAIN READING OF GAGE LOCATED NEAR W R /�/ RESIDUAL PRESSURE WITH VALVE IN TEST
TEST SUPPLY TEST CONNECTION: PSI CONNECTION OPEN WIDE 7.s" PSI
UNDERGROUND MAINS AND LEAD IN CONNECTIONS TO SYSTEM RISERS FLUSHED BEFORE CONNECTION MADE TO SPRINKLER PIPING.
VERIFIED BY COPY OF THE U FORM NO. 35B ❑ YES ❑ NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER- Ek /S771%)4 ,
GROUND SPRINKLER PIPING ❑ YES ❑ NO
BLANK TESTING NUMBER US USED LOCATIONS NUMBER REMOVED
GASKETS /o
WELDED PIPING YES ❑ NO
iF YES ...
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING PROCEDURES COMPLY
WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3 d YES ❑ NO
WELDING COMPLIANCE YOU CERTIFY THAT THE WELDING WAS PERFORMED BY WELDERS QUALIFIED IN
COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST AWS D10.9, LEVEL AR -3 61, YES ❑ NO
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE WITH A
DOCUMENTED QUALITY CONTROL PROCEDURE TO INSURE 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 °6 YES 0 NO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO ENSURE THAT ALL
(DISCS) CUTOUTS (DISCS) ARE RETRIEVED? sL YES ❑ NO
HYDRAULIC NAME PLATE PROVIDED IF NO, EXPLAIN
DATA
NAMEPLATE elk YES ❑ NO
DATE LEFT IN SERVICE WIT CONTROL VALVES OPEN:
REMARKS / — Z -/
NAME OF SPRINKLER CONTRACTOR
A ep20F -sra sc. Ft r , rePts .,,.
TESTS WITNESSED BY
SIGNATURES FOR PROPERTY OWNER (SIGNED) TITLE DATE
FOR' INKLER CONTRACTOR (�jG�D) TITLE DATE
..�
ADDITIONAL EXPLANATION A . i NOTES
•
•