Report (102) Contractors Material and Test Certificate for boveground Piping
(-1)5PROCEDURE 2z l t 0937_,_
Upon completion of work,inspection 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 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: let( (1st-4%4.Z F.k S'f 1u r l ;5 c.
PROPERTY ADDRESS: 1104 3 Swl A p flt&IT I 7 *Mx)/)a. 1700:17 DATE:12—L7^t"
PLANS
ADDRESS ACCEPTED BY APPROVING AUTHORITIES(NAMES) C� (� C�1 ''v,� f
INSTALLATION CONFORMS TO ACCEPTED PLANS BYES 0 NO
EQUIPMENT USED IS APPROVED 'ES 0 NO
IF NO,EXPLAIN DEVIATIONS
HAS PERSON IN CHARGE OF FIRE EQUIPMENT BEEN INSTRUCTED AS KjYES 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 A YES 0 NO
2.CARE AND MAINTENANCE INSTRUCTIONS : A 5 0 NO
3.NFPA 25 ►. YES ❑NO
LOCATION SUPPLIES BUILDINGS At./
OF SYSTEM
YEAR OF ORIFICE TEMPERATURE
MAKE MODEL MANUFACTURE SIZE QUANTITY RATING
Ir w1.t vV7g0 �v aft Io(� ill
SPRINKLERS V: 1;L V $ 0 G't If L
IKCArevt:( �/3i Io 'Zdc I iZoo
,r.'OUNCL V_�% Zoc1q `rt. Z I r
PIPE AND TYPE OF PIPE C,7V pC. I k k-is 0 Btu,
FITTINGS TYPE OF FITTINGS tri L d I
MAXIMUM TIME TO OPERATE
ALARM ALARM DEVICE THROUGH TEST CONNECTION
VALVE
OR FLOW TYPE MAKE. MODEL. MN SEC
INDICATOR `( Tt[[tf Vit
_ 6�1 0 3 6
sosDRY V VE 7 Q.O.D.
MAKE M EL SERIAL NO. /AAKE MODEL SERIAL NO.
TIME TO TRIP TIME WATER ALARM
THROUGH TEST WATER AIR TRIP POINT REACHED OPERATED
DRY PIPE CONECTION P'. SSURE PRE : ' AIR PRESSURE TEST OUTLET PROPERLY
OPERATING MIN SEC 'SI PSI MIN SEC YES NO
TEST WITHOUT
O.O.D.
WITH
O.O.D.
IF NO,EXPLAIN ,
OPERATION 0 ' UMATIC 0 ELECTR . 0 HYDRALIC
DELUGE AND
PREACTION PIPING SUPERVISED \ YES 0 NO DE 11' TING MEDIA SUPERVISED 0 YES 0 NO
VALVES
DOES VALVE OPERATE FROM THE : UAL TRIP,REM. ,OR BOTH 0 YES 0 NO
CONTROL STATIONS
IS THERE AN ACCESSIBLE FACILITY IN EAC •i'CULT IF NO,EXPLAIN
FOR TESTING 0 YES 0 NO ,
DOES EACH C I: UIT OPERATE DOES EACH CIRCUIT MAXIMUM TIME TO
MAKE MODEL SUPERVISI••• LOSS ALARM? OPERATE VALVE RELEASE OPERATE RELEASE
YES NO YES NO MIN SEC
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LOCATION MAKE& SE MI G STA - -'ESSURE RESIDUAL PRESSURE FLOW RATE
PRESSURE &FLOOR MODEL (FLOWING)
REDUCING ,11 (PSI) OUTLET(PSI) INLET(PSI) OUTLET(PSI) FLOW(GPM)
VALVE TEST
HYDROSTATIC:Hydrostatic tests shall be made at not less th• 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 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 PSI(0.1 bars)in 24 hours.
ALL PIPING HYDROSTATICALLY TESTED AT ZQe/PSI_B�SNOR�HRS
IF NO,STATE REASON
DRY PIPING PNEUMATICALLY TESTED 0 YES 0 NO
EQUIPMENT OPERATES PROPERLY li
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT ADDITIVES AND CORROSIVE CHEMICALS,
SODIUM SILICATE OR DERIVITIVES OF SODIUM SILICATE,BRINE,OR OTHER CORROSIVE CHEMICALS
T USED FOR TESTING SYSTEMS OR STOPPING LEAKS?
V EYES ❑ NO
E WITH
T IN
TESTS TTERAIN T SUPPLY TESF T
COAGE NNECTION� PSI WATER UAR BARS) CONNECTION OPENN 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 0 NO OTHER EXPLAIN
FLUSHED BY INSTALLER OF UNDER- �/ 0YES NO
GROUND SPRINKLER PIPING Jj
IF POWDER-DRIVEN FASTENERS ARE USED IN 0 YES 0 NO • IF NO,EXPLAIN
CONCRETE,HAS REPRESENTATIVE SAMPLE p
TESTING BEEN SATISFACTORILY COMPLETED? fki
hlggR REMOVED
BLANK TESTING NUMBER USED I LOCATIONS
GASKETS ` m
WELDED PIPING 0 YES r NO •
IF YES....
DO YOU CERTIFY AS THE SPRINKLER CONTRACTOR THAT'WELDING 0 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 0 YES 0 NO
QUALIFIED IN COMPLIANCE WITH THE REQUIREMENTS OF AT LEAST A t
AWS D10.9,LEVEL AR-3? ,�I
DO YOU CERTIFY THAT WELDING WAS CARRIED OUT IN COMPLIANCE
WITH A DOCUMENTED QUALITY CONTROL PROCEDURE TO ENSURE YES 0 NO
THAT ALL DISCS ARE RETRIEVED,THAT OPENINGS IN PIPING ARE 0
SMOOTH,THAT SLAG AND OTHER WELDING RESIDUE ARE REMOVED,
AND THAT THE INTERNAL DIAMETERS OF PIPING ARE NOT PENETRATED? YES 0 NO
CUTOUTS DO YOU CERTIFY THAT YOU HAVE A CONTROL FEATURE TO 0 A
-(DISCS ENSURE THAT ALL CUTOUTS(DISCS)ARE RETRIEVED? •v -
HYDRAULIC NAMEPLATE PROVIDED I IF NO,EXPLAIN
DATA YES 0-NO
NAMEPLATE 7f 1-Z ,t ir
DATE LEFT IN SERVICE WITH ALL CONTROL VALVES OPEN /
REMARKS
NAME OF SPRIN. �" C ACTOR 'i Fr.t—
TEST TITLLJE TE
WITNESSED FOR PRO' TY O R. IGNED) Y �/ J ,�
BY �" / t//l
FOR S'RIN `eh='a► TOR(SIGNED) TITLE DATE
‘10y-- ir,.tA Obn 11-Z7-ii
ADDITIONAL EXPLANATION AND NOTES
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