Report F:pcc- 2D oz
INSPECTION,TESTING,AND MAINTENANCE 72-101
INSPECTION AND TESTING FORM
DATE: lr-/B-,q
TIME: 930
SERVICE ORGANIZATION PROPERTY NAME(USER)
Name: 1,i0WALIPS %1-0-CTiO4//G0 Name: 4P..)ILA-- T14.44z-v
Address: 3247 it/A/ ZQ Mgr Address: 13 9L€ SW 7AG/Fs'/C 146 1"
Representative: N4 77W is1 s/141/LO Y Owner Contact: Q0:1 W 1 NQ'STPLCF S
License No.: 04..4LEA Telephone: SOS-e-Z -135 T 0
Telephone: ?^T4-4!1.6785
MONITORING ENTITY APPROVING AGENCY
Contact: "w/L i#Pt ,6L-EiTPoN/C.S Contact: G,TTY OF • 1 4.P
Telephone: /84.621;•161204 Telephone: S'S-7/6-za/s9
Monitoring Account Ref.No.: LaPsseo/
TYPE TRANSMISSION SERVICE
❑ McCulloh ❑ Weekly
LI Multiplex ❑ Monthly
igital ❑ Quarterly
❑ Reverse Priority ❑ Semiannually
❑ RF ISKAnnually
❑ Other(Specify) ❑ Other(Specify)
Control Unit Manufacturer: '014.,E1I7- he-L./1444T Model No.: 6ZOt0
Circuit Styles: 414145.1
Number of Circuits: //
Software Rev.: 44010/
Last Date System Had Any Service Performed: A/iiv fA ST$.L..
Last Date that Any Software or Configuration Was Revised: A/A
ALARM-INITIATING DEVICES AND CIRCUIT INFORMATION
Quantity Circuit Style
41 al-AAA $ _ Manual Fire Alarm Boxes
Ion Detectors
Z Ci41.011 16 Photo Detectors
3 &LAS 3 8 Duct Detectors
Heat Detectors
/
C44405 $ Waterflow Switches
3 C4-AOS 3 Supervisory Switches
Other(Specify):
Alarm verification feature is disabled , enabled
(NFPA Inspection and Testing,1 of 4)
FIGURE 10.6.2.3 Example of an Inspection and Testing Form.
2002 Edition
72-102 NATIONAL FIRE ALARM CODE
ALARM NOTIFICATION APPLIANCES AND CIRCUIT INFORMATION
Quantity Circuit Style
WASS a Bells
%Z r7Ld� a Horns
Chimes
Z e 6 . Strobes
Speakers
Other(Specify):
No.of alarm notification appliance circuits: 'Y
Are circuits monitored for integrity? i`5r Yes ❑ No
SUPERVISORY SIGNAL-INITIATING DEVICES AND CIRCUIT INFORMATION
Quantity Circuit Style
Building Temp.
Site Water Temp.
Site Water Level
Fire Pump Power
Fire Pump Running
Fire Pump Auto Position
Fire Pump or Pump Controller Trouble
Fire Pump Running
Generator In Auto Position
Generator or Controller Trouble
Switch Transfer
Generator Engine Running
Other:
SIGNALING LINE CIRCUITS
Quantity and style of signaling line circuits connected to system(see NFPA 72,Table 6.6.1):
Quantity Style(s)
SYSTEM POWER SUPPLIES
(a)Primary(Main): Nominal Voltage ,Z D&ZC'. Amps Z1iVlr
Overcurrent Protection: Type Amps
Location(of Primary Supply Panelboard): FL.— 1 e (MALE 'Ptye.. L.
Disconnecting Means Location: GKT 18
(b)Secondary(Standby):
2. A Storage Battery:Amp-Hr.Rating 9 1P$
Calculated capacity to operate system,in hours: 74. 24 60
Engine-driven generator dedicated to fire alarm system:
Location of fuel storage:
TYPE BATTERY
• Dry Cell
❑ Nickel-Cadmium
Sealed Lead-Acid
❑ Lead-Acid
❑ Other(Specify):
(c) Emergency or standby system used as a backup to primary power supply,instead of using a secondary power supply:
Emergency system described in NFPA 70,Article 700
Legally required standby described in NFPA 70,Article 701
Optional standby system described in NFPA 70,Article 702,which also meets the performance
requirements of Article 700 or 701.
(NFPA Inspection and Testing,2 of 4)
FIGURE 10.6.2.3 Continued
2002 Edition
INSPECTION,TESTING,AND MAINTENANCE 72-103
PRIOR TO ANY TESTING
NOTIFICATIONS ARE MADE Yes No Who Time
Monitoring Entity Ll rot//GLITS1 e;sp
Building Occupants �, ❑ GismisselAti, _ tscs
Building Management 'v. U Ii 4 V Y7 y 6;pp
Other(Specify) ❑ ❑
AHJ Notified of Any Impairments ❑ ❑
SYSTEM TESTS AND INSPECTIONS
TYPE Visual Functional Comments
Control Unit }1.
Interface Equipment
Lamps/LEDS
Fuses ❑ ❑
Primary Power Supply *L. i$[
Trouble Signals Ni—
Disconnect Switches
Ground-Fault Monitoring X.
SECONDARY POWER
TYPE Visual Functional Comments
Battery Condition
Load Voltage
Discharge Test
Charger Test
Specific Gravity LI
TRANSIENT SUPPRESSORS ❑
REMOTE ANNUNCIATORS
NOTIFICATION APPLIANCES
Audible VC Y4r
Visible
Speakers ❑ O
Voice Clarity ❑
INITIATING AND SUPERVISORY DEVICE TESTS AND INSPECTIONS
Device Visual Functional Factory Measured
Loc.&S/N Type Check Test Setting Setting Pass Fail
Pd3WE' _ L J 'e ❑
}e.1 71V�. Tomi R► ` - xe
ti ❑
_AC.Tt• 3 t_
tMt>r ❑
ELJI T+ECAL. s-to I[E_ ID
"-renews_ -Fut.i.'ta i Vr.. J
i/duL't M6.ninmit NI- 1 _ X. ❑
Comments:
(NFPA Inspection and Testing,3 of 4)
FIGURE 10.6.2.3 Continued
2002 Edition
• • 1
72-104 NATIONAL FIRE ALARM CODE
EMERGENCY COMMUNICATIONS EQUIPMENT Visual Functional Comments
Phone Set ❑ ❑
Phone Jacks ❑ ❑
Off-Hook Indicator ❑ ❑
Amplifier(s) ❑ ❑
Tone Generator(s) ❑ ❑
Call-in Signal ❑ ❑
System Performance I4
Device Simulated
Visual Operation Operation
INTERFACE EQUIPMENT
(Specify) 'AP-10034y DP ❑
(Specify) ❑ ❑ ❑
(Specify) ❑ ❑ ❑
SPECIAL HAZARD SYSTEMS
(Specify) ❑ ❑ ❑
(Specify) ❑ ❑ 0
(Specify) ❑ ❑ ❑
Special Procedures:
Comments:
SUPERVISING STATION MONITORING Yes No Time Comments
Alarm Signal ❑
Alarm Restoration ❑
Trouble Signal $. ❑
Supervisory Signal ❑
Supervisory Restoration Alc ❑
NOTIFICATIONS THAT TESTING IS COMPLETE Yes No Who Time
Building Management e ❑ CLAVpMl1Ly
Monitoring Agency ❑ pa ILIA
Building Occupants ❑ 41ppbWii,i.--
Other(Specify) ❑ ❑
The following did not operate correctly:
System restored to normal operation: Date: Z-Air iy Time:
THIS TESTING WAS PERFORMED IN ACCORDANCE WITH APPLICABLE NFPA STANDARDS.
Name of Inspector: Date: Time:
Signature:
Name of Owner or Representative: /• 444161/1- y .
Date: f.-.l6--//,/ Time:
Signature: ! • • -
(NFPA Inspection and Testing,4 of 4)
FIGURE 10.6.2.3 Continued
2002 Edition