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1 Property Information flos'",- '' •0 1.,
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Cylinder Size c.a.( oir\ ) 4 Last Hydrostatic Test Date 1...„C) i 2... Flow Points Capacity Used
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'System Location ' 1,1/4.,)aU System Mir 4-.1.1,‘ St.A.( _ Model# K.,-- t f.) a
IFuel/Heat Shut Off_ -
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(7 Electrical ti ..e.- integral Make Up Air Snot Down....---
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I Cooking Appliances
Left to Right with Sizes and Coverage Nozzles
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Date
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CornrnentSjOhly. -,1... i•tP,Fr NO •
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1 i Manual Actuators are Unobsti,...c,,ec
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1 2 !Tamper indicators& Seats Intact i ' : 2 2
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I 4 l !No 00\iidias Physical Damage 1 - :.. Z .-.‘
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1 5 Gauge( ore Readings(Stored
Pressure within Proper,inii.s
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I 6 I 1610w-Off Caps in Place &Undamaged
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I 7 I Hoods Ducts.Filters in Place an ,..o Ciean CSC ,-.: ,• 7,... 3 ....
1 8 Hood,Ducts&Protected Coop,, " z_ng Appliances Have
Not Been Replaced Modifies or Relocated .2 Z. I r.
2 i T [Automatic Detection/Manual Actuation Functioned - - -
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'Correctly
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t r : em'ca�� •t,,y,p "ng neelred '`'GE!tfoania Cgde of Regy a oils:-j,ue;f9<:=4: ; V, t u8 a , 2 of 2
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Property Information r-s'r w r
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'BondingName "r p 0 �1 Z.. A. ># - - ,: •i'va e _ ..
;Address LA -1 5 {".. )N kc iJ a�i`. L:a �H `JOG$1 7, l e.1
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2 2 T Fuel Shut-Off Operated Correctly " 2-3 /� ( zip
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, -3 T Regulator Tested&is within Acceptable Limits 3 3<
Manual P,esetRctay Funs Oned orrectl, ____"
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= a T Of Applicable) --- - - I P - - --
M All Agent Containers within Acceptat e 4vd' stal c
Test Dates . .......... _.....__.,_..____
All Auxiliary pressure Containers anal r Hose _
3 2 h. Assemblies within Acceptable Hydrostatic Test Dates __.__..._.
3 3 I M 'Cartridge Weights within Acceptable i_,rn is - 7 : ' I F.
I d 'Liquid Level within Acceptable Limits
'3 M - - ^ . t..
(Non-pressurized?
No Signs of Corrosion in Agent Cylinder
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5 tit ,..
(Non-pressurized) " "
I 3 6 M Distribution Piping Unobstructed and ent guc:us ` ' , _
3 7 M Nozzles are Correct.Clean&Properly Air*rec I " ' ? •` 2 I
3 8 I M !Fixed temp Fusible Metal Alioy Type:Detectors Replaced! -a.. I 4
Fixed-Temp;Other Than Fusible Meta Alio 'yoe' S. z
3 9 M Neat Detectors Maintained or Replaced r 10V
Auxiliary Such as Water valves
? 10 M• FunctonedgCor ectly y 4.L._......__.. ___ 7r
3 1 t M Internal Maintenance as Requ=red Dy Manufacturer ,e '
( D=Deficiency C=Comment (Indicate type)
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E ; Check mere it additional Deficiencies and Cvr„r"e=;ts are i:sted on Form AES ii ',,,'"'",''e".a•,a-=" =
{ 0 See Correction Form AES 10 for corrected oefic:enues ti_.., ,auac'nec
I hereby certify that the fire protection equipment listed above has been fully inspected, tested, and maintained on this date by
the company indicated above,in accordance with CCR, Title 19, Sections 901 to 906 and that the equipment is fully operable
except as noted in the"Deficiencies and Comments"section of this form
Print Name o ,,,, tfV1, t Ci
Signature s- I.- e, I r