Report (28) }--Ps 20 l l OcoGD
Contractor's Material and Test Certificate for Aboveground Piping
PROCEDURE
Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owner's representative
(hereinafter defined as property owner). 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 that the property owner's authorized representative is a legal signatory and fully representative of the property owner and that by the
property owner's or property owner's authorized representative's signature,the property owner accepts full responsibility for the system as
installed and agrees that it is in compliance with the applicable approving authority's requirements and local ordinances.
Property Name , l/ lei
Date f z1 1
Property Address,/61) r< � � �t� %��`
/(2.3-56
� �� s�1J /317' At T6A-yep, OrL ,7%2013
Accepted by Approving Authorities(Names)
�/��/�/- /�/�
Address " " v " " D
Plans
Installation conforms to accepted PlansYes 0 No
Equipment used is approved jit Yes 0 No
If no,explain deviations
Has the property owner or property owner's authorized representative been
instructed as to the location of control valves and care and maintenance of this
new equipment? Yes 0 No
If no,explain
Have copies of the following been given to the property owner or property
Instruction owner's authorized representative?
1. System Components Instructions 0 Yes 0 No
2. Care and Maintenance Instructions 0 Yes 0 No
3. NFPA 25
0 Yes 0 No
Location
Of System Supplies Buildings 4225-5-6
5 3-v 513 /3 ' ,4am
Year Temperature
Make Model of Manufacture Orifice S'zeQuantity Ratin
Sprinklers RFc_ l o� , . % t49; /()d9
Pipe and Type of Pipe < / / p _-
Maximum
$T / 1/// time to operate
Alarm Valve Alarm Device ="` ' through test connection
or Flow Type Make ',Model Minutes Seconds
Indicator
Dry Valve Q.O.D.
Make Model Serial No. Make. Model Serial N.
Time to trip Trip Point •.. , - er
through test Water Reached Test Alarm Operated Properly
Dry Pipe connection* Pressure Pres - e Outlet*
Operast ting Min/Sec psi psi psi /Sec Yes No
Te
w/o Q.O.D.
with I e.0.
'o,explain
`measured from time inspectors test opened(NFPA 13 only requires the 60-second limitation in specific sections)
i
Operation 0 Pneumatic 0 Electric 0 Hydraulic
Piping Supervised 0 Yes 0 NoJ Detecting Media Supervised 0 Yes Pi o
Does valve operate from the manual trip,remote,or both control stations? ■ 0 No
ifs ccessibte facility in each circuit for testing? If no,explain
Deluge&
Preaction ❑ Yes 0 No
Valves ach circuit operate Doe . ircuit operate valve Maximum time to operate
Make Model supervisio alarm? release? release
Yes ... Yes No Min Sec
Location Make and Residual Pressure
Pressure and Floor ,, - Setting Static Pressure (flowing) Flow Rate
Reducing
Valve Tes Inlet(psi) Outlet(psi) Inlet(psi) it. - • i) Flow(gpm)
HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi(13.6 bar)for two hours or 50 psi(3.4 bar)above static
pressure in excess of 150 psi(10.2 bar)for two hours. Differential dry-pipe valve clappers shall be left open during the test to prevent
Test damage. All aboveground piping leakage shall be stopped.
Description PNEUMATIC:Establish 40 psi(2.7 bar)air pressure and measure drop,which shall not exceed 1 1/2 psi(0.1 bar)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 bar)in 24
hours.
All piping hydrostatically tested at0_12psi(_bar)for hours If no,state reason
Dry piping pneumatically tested 0 Yes 0 No
Equipment operates properly 0 Yes 0 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 system or stopping leaks?
lEr Yes 0 No
Drain Reading of gauge located near water supply test connection Residual pressure with valve in test connection open wide
Tests Test psi(_bar) _psi(_bar)
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 0 No Other Explain
Flushed by installer of underground sprinkler piping 0 Yes 0 No
If powder-driven fasteners are used in concrete,has 0 Yes 0 No If no,explain
representative sample testing been satisfactorily
completed?
Blank Number sed Locations Number Removed
Testing
Gaskets
Welded Piping 0 YES 1NO If Yes...
Do you certify as the sprinkler contractor that welding procedures comply with the
Requirements of at least AWS B2.1? 0 Yes 0 No
Do you certify that the welding was performed by welders qualified in compliance
Welding With the requirements of at least AWS B2.1? 0 Yes 0 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? 0 Yes 0 No
Cutouts Do you certify that you have a control feature to ensure that all cutouts(discs)are
(Discs) Retrieved? f,,Yes 0 No
Hydraulic Nameplate provided XYes 0 No If no,explain
Data
Nameplate
Remarks Date left in service with all control valves open
Name of Sprinkler Contractor FtSIV ME ReCrre-87 ._____________
Tests Witnessed by:
Signatures
For property owner(printed name) Signature Title Date
_ 4 k-=- Pig't . fts?rc jilK n ./2../.$42_,
For nnk el* ntractor(printed name) Signature Title ate
Additional Explana ion and Notes: