Report Contractor's Material and Test Certificate for Aboveground Piping
PROCEDURE `' '1 -� a o s v` 10'� R L- T
Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owne '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: Pediatrics Associates of the Northwest
PROPERTY ADDRESS: 7150 SW Dartmouth Street Tigard, Oregon DATE: 11.5.15
ACCEPTED BY APPROVING AUTHORITIES(NAMES) The City of Tigard
PLANS
ADDRESS 13125 SW Hall Blvd. Tigard, Oregon
INSTALLATION CONFORMS TO ACCEPTED PLANS ®YES ❑NO
EQUIPMENT USED IS APPROVED ®YES ❑NO
IF NO,EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS IN YES ❑NO
TO LOCATION OF CONTROL VALVES AND CARE AND MAINTENANCE
IF NO,EXPLAIN
INSTRUCTIONS
HAVE COPIES OF THE FOLLOWING BEEN LEFT ON THE PREMISES?
I.SYSTEM COMPONENTS INSTRUCTIONS ®YES ❑NO
2.CARE AND MAINTENANCE INSTRUCTIONS ®YES ❑NO
3.NFPA 25 ®YES ❑NO
LOCATION SUPPLIES BUILDINGS Throughout building at 7150 SW Dartmouth
OF SYSTEM
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QUANTITY RATING
TYCO TY-FRB 2015 1/2" 80 155
SPRINKLERS TYCO TY-FRB 2015 1/2" 76 200
TYCO RF-LL 2015 1/2" 8 155
PIPE AND TYPE OF PIPE Schedule 40 Dynathread
FITTINGS TYPE OF FITTINGS Black cast iron
MAXIMUM TIME TO OPERATE
ALARM ALARM DEVICE THROUGH TEST CONNECTION
VALVE
OR FLOW TYl?F. MAKE MODEI. MIN SEC
INDICATOR Flow switch 0 . 32
DRY VALVE Q,(1D-
MAKE MODEL SERIAL-NO, MAKE MODEL SERIAL NO.
TIME TO TRIP TIME WATER ALARM
THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
DRAPE CONECTION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROPERLY
OPERATING MIN SEG PSI PSI PSI MIN SEC YES NO
TEST WITHOUT
O.O.D.
WITH
Q-00-14
IF NO,EXPLAIN
OPERATION ❑ PNEUMATIC ❑ E ECT-RIG ❑ HYDRALIC
DELUGE-AND
PRERGTION PIPING SUPERVISED ❑ YES ❑ NO DETECTING MEDIA SUPERVISED ❑YES ❑NO
VALVES
DOES VALVE OPERATE FROM TTF Nn i M n .oAL_-R rasp REMOTE,OR BOTH ❑ YES ❑ NO
CONTROL STATIONS
IF NO,EXPLAIN
FOR TESTING ❑ YES ❑ NO
DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM-TIME-TO
MAKE MODEL __ - - 01. _I-- • -• . „ OPERATE VALVE RELEASE OPERATE RELEASE
YES NO YES NO MIN SEC
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LOCATION MAKE-& SHTI4NO STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE
PRESSURE &FLOOR MODEL (-FLOWING)
RAGING LET-(PSI) OUTLET(PSI) INLET(PSI).OUTLET(PSI) FLO—(GRM3
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 11/2 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 1' PSI(0.1 bars)in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT 210 PSI BARS FOR 2 HRS IF NO,STATE REASON
DRY PIPING PNEUMATICALLY TESTED ❑ YES ❑ NO
EQUIPMENT OPERATES PROPERLY ® YES ❑ 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"
YES ❑ 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 ❑ YES ❑ NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER-
GROUND SPRINKLER PIPING ® YES ❑ NO
IF POWDER-DRIVEN FASTENERS ARE USED IN ❑ YES ❑ NO IF NO,EXPLAIN
CONCRETE,HAS REPRESENTATIVE SAMPLE
TESTING BEEN SATISFACTORILY COMPLETED"
BLANK TESTING NUMBER USED LOCATIONS NUMBER REMOVED
GASKETS
WELDED PIPING ® YES ❑ NO
IF YES....
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING IN YES ❑ 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 ❑ 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 [23 YES ❑ NO
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 ® YES ❑ 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
NAME OF SPRINKLER CONTRACTOR
McKinstry Co, LLC
TEST
WITNESSED FOR PROPERTY OWNER(SIGNED) TITLE DATE
BY
FOR SPRINKLER CONTRACTOR(SIGNED) TITLE DATE
ADDITIONAL EXPLANATION AND NOTES
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