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Report (92) rp5 r Contractor's Material and Test Certificate Aboveg.foZiPiping op PROCEDURE `-by U W =,A _' 'P-C.k J -- , Upon completion of work,inspection and tests shall be made by the contractor's representative and witnessed by an owner`§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 apprbving 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 requirit -ements or local ordinances. PROPERTY NAME: �,3 '1 L h ,S ' .a \�S •t. k. 1t�. PROPERTY ADDRESS: , 0 .. '_- t .. '11•a- DATE: -7-PC7-17 7• � PLANS ACCEPTED BY APPROVING AUTHORITIES(NAMES) Col 0.c, .A._ie,(61 1 ADDRESS �] INSTALLATION CONFORMS TO ACCEPTED PLANS YES 0 NO , EQUIPMENT USED IS APPROVED X YES 0 NO IF NO,EXPLAIN DEVIATIONS HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS KYES 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.NEPA 25 YES 0 NO LOCATION SUPPLIES BUILDINGS OF SYSTEM YEAR OF ORIFICE ' TEMPERATURE MAKE MODEL MANUFACTURE SIZE QUANTITY RATING ti Y 1a ' I. 1 " tit' SPRINKLERS ,•L C k,: 111D i�r'J. d 0 l Y� PIPE AND TYPE OF PIPE C..N\).0 y Sc1"�) 0 } Q FITTINGS TYPE OF FITTINGSS .Q,�• lG-Y©e' MAXIMUM TIME TO OPERATE ALARM ALARUDEVICX THROUGH TEST CONNECTION VALVE OR FLOW TYPE ]MAKE WHIM. MTN SEC INDICATOR F-10 .3 � �. a LA 6 DRY VALVE Q.O.D. MAKE MODEL SERIAL NO. MAKE MODEL SERIAL NO. TIME TO TRIP TIME WATER ALARM THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED DRY PIPE CONECI'ION PRESSURE PRESSURE AIR PRESSURE TEST OUTLET PROP ILY OPERATING MIN 0 _ Sgs 1, d i 1 PSI �MIN NO TEST WITHOUT (40 ai x- 1 O.O.D. WTIH Q 0.D IF NO,EXPLAIN OPERATION 0 PNEUMATIC 0 ELECTRIC 0 HYDRALIC —/^ DELUGE PREACTION PIP 1 I •' ': ISED 0 YES 0 NO DETECTING MEDIA SUPERVISED ES, 0 NO VALVES —• DOES VALVE OPERATE FRO - . AL TRIP,REMOTE,OR BOTH 0 YES '0 NO CONTROL STATIONS , IS THERE AN ACCESSIBLE FACILITY IN •. 1'CUT 1- • EXPLAIN FOR TESTING 0 YES ■ • DOES EACH CIRCUIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO MODEL SUPERVISION LOSS ALARM? OPERATE VALVE RELEASE •'-1: TE RELEASE YES I NO YES NO MIN EC Page 1 of 2 LOCATION MAKE& SETTING STATIC PRESSURE RESIDUAL PRESSURE FLOW RATE PRESSURE &FLOOR MQDEL (FLOWING) REDUCING LET(PSI) I OUTLET(PS INLET(PSI)(OUTLET(PSI) FLOW(GPM) VALVE TEST #IYDROSTATIC: °drostatic tests shall be made at not less than 200 PSI(13.6 bars)for 2 hours or 50 PSI(3.4 bars) TEST above stats • • 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 _*I SI BARS FOR 2 ARS IF NO,STATE REASON DRY PIPING PNEUMATICALLY TESTED 1 YES 0 NO 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? A YES ❑ NO TESTS DRAIN READING OF GUAGE LOCATED R 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 /6 YES 0 NO OTHER EXPLAIN FLUSHED BY INSTALLER OF UNDER- GROUND SPRINKLER PIPING IS,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? BLANK TESTING NUMBER USED I LOCATIONS NUMBER REMOVED GASKETS WELDED PIPING &YES 0 NO IF YES.... DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT WELDING `I 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 AWS 010.9,LEVEL AR-3? IX)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 j�YES 0 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 OYES 0 NO (DISCS) ENSURE THAT ALL CUTOUTS(DISCS)ARE RETRIEVED? HYDRAULIC NAMEPLATE PROVIDED IF NO,EXPLAIN DATA pq YES 0 NO NAMEPLATE DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN REMARKS NAME0 1 KLE$LON ce v ie/ly I CTC d \ TEST ` `t WITNESSED FOR PROPERTY OWNER(SIGNED) TITLE DATE BY FOR •. ' KL • . TRACTOR(SIGNED) TITLE DATE 1) ADDITIONAL EXPLANA WON I/111 7/2i3/) . , Page 2of2