HomeMy WebLinkAboutFAI20-0020 010-250-006 CF FES 3-13-24 * et h- illilio„ 6i 1 1111 1111" ii.11o-i Iil ' II !" , Y,{ 1.i .I-liu ,0;1II, we I. i. •1_ 1I•1 i ii.
Fire Extinguishing,System Inspection,Testing,and Maintenance Report o
Property Information ,,�Q��� Aso Contractor or Licensed Owner Information
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Building Name Orchard Hospital 9 ., ',-(C Name Voltage Specialists
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!Address 240 Spruce Street 3 �� Address 370 Apple Lane
1� E MP City Paradise St. CA Zip 95969
tlCity Gridley (License# 880862 (Phone (530)624-4514
!Contact Person Mike Newton I LI SFM IJob#
!Phone701-7687 I M] CSLB !Misc.
System Information
Cylinder Size 3 Last Hydrostatic Test Date Flow Points Capacity Used 8
!System Location On wall by sink System Mfr. Ansul2010 Model# R102
(Fuel/Heat Shut Off:
,!Gas# Electrical# Integral Make Up Air Shut Down
Items I #of Items Dimensions I Nozzle Nozzle Nozzle Total
Model# I Flow Points I Qty I
Flow Points
Hoods I 1 I 54"x80" I - I - I - I 0
(Plenums I 1 I 40" I 1W I 1 I 1 I 1
(Ducts I 1 I 16x17" I 2W I 2 I 1 I 2
Cooking Appliances
Left to Right with Sizes and Coverage Nozzles
Appliance Name
Nozzle I Nozzle I Total Appliance Name Nozzle I Nozzle I Total
Model Flow Points Flow Points Model Flow Points Flow Points
Range I 1F&245 I I 3 I I I I
Griddle I 260 I I 2 II I
I I I II I
III' I
I I
I I II
I I
I
Fixed Temperature Sensing Elements
(such as Fusible Links)
QuantityTempMfr Install
(luantit Tem Mfr Install
I I Date I Date y I p I Date I Date
1 I 450 I 2024 I 3/13/24 I I I I I
I I I II I I I 1
Inspection, Testing and Maintenance
I = Inspection T =Test M=Maintenance • P=Pass F=Fail N/A=Not Applicable
Item I I Description I NFPA 17A CA I Date I ed.Reference Comments Only I P,F,N/A
1.1 I I 'Manual Actuators are Unobstructed I 7.2.2(2) 103/13/24 I I P
(i.e.remote pull station)
1.2 I I (Tamper Indicators&Seals Intact I 7.2.2(3) 103/13/24 I I P
1.3 I Maintenance Tag in Place 7.2.2(4) 03/13/24 I P
I Title 19*906 I I
I I
1.4 I I INo Obvious Physical Damage I 7.2.2(5) 103/13/24 I I P
1.5 I Gauge Readings within Proper Limits 7 2 2(6) I
IN/A
(Stored pressure)
1.6 I I (Blow-off Caps in Place&Undamaged I 7.2.2(7) 103/13/24 I I P
1.7 I I (Hoods,Ducts, Filters in Place and Clean I CFC 904.11.6.3 103/13/24 I I P
I (Not Been Replacood, Ducts&Pred,Mod otected ed or ReloCookingccated li es Have I 7 2 2(8) 103/13/24 I I P
1°6°2.1 I T (Automaticorrectly Detection/Manual Actuation Functioned I 7.3.3.4 103/13/24 I I P
C
Wet Chemical Pre-Engineered California Code of Regulations -Title 19 Semi-Annual 2 of 2
Fire Extinguishing System Inspection,Testing,and Maintenance Report
'6171Property information {,-,- .� ,o Contractor or Licensed Owner Information
Building Name Orchard Hospital 3, C )5',.
i Name Voltage Specialists
,Address 240 Spruce Street ,,�-.S Q' Job#
`City Gridley p e OP
Inspection, Testing and Maintenance
I =Inspection T =Test M=Maintenance P=Pass F=Fail N/A=Not Applicable
Item I Description NF Date Comments Only P,F,N/A
ed.R
ed.Referfer CAence
2.2 I T Fuel Shut-off Operated Correctly 7.3.3.4 03/13/24 P
2.3 I T Regulator Tested&is within Acceptable Limits 7.3.3.4 03/13/24 P
2.4 I T Manual Reset Relay Functioned Correctly 7.3.3.4 03/13/24 P
(if applicable)
3.1 I M All Agent Containers within Acceptable Hydrostatic
Test Dates 7.5.1(1) 03/13/24 P
3.2 I M jAII Auxiliary Pressure Containers and/or Hose 7 5 1(2)(3) 03/13/24 P
ssemblies within Acceotable Hydrostatic Test Dates
3.3 I M Cartridge Weights within Acceptable Limits 7.3.3.1(2) 03/13/24 P
3.4 I M Liquid Level within Acceptable Limits 7.3.3.1(2) 03/13/24 P
(Non-pressurized)
3.5 I M No Signs of Corrosion in Agent Cylinder 7.3.3.1(2) 03/13/24 P
(Non-pressurized)
3.6 I M Distribution Piping Unobstructed and Contiguous 7.3.3.1(3) 03/13/24 P
1.7 I M Nozzles are Correct,Clean&Properly Aimed 7.3.3.1(2) 03/13/24 P
itloS.g I M Fixed Temp Fusible Metal Alloy Type Detectors Replaced 7.3.4 03/13/24 P
3.9 I M Fixed-Temp(other than fusible metal alloy type) 7 3 5 N/A
&Heat Detectors Maintained or Replaced
3.10 I M Auxiliary Equipment Such as Water valves 7.3.3.1(2) N/A
Functioned Correctly
3.11 I M Internal Maintenance as Required by Manufacturer Title 19§904.7 N/A
D=Deficiency C=Comment (Indicate type)
Item Date Riser D C Deficiencies and Comments
Indicate all equipment devices and pails that were re+aired or replaced
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❑Check here if additional Deficiencies and Comments are listed on Form AES9 Number attached:
iJ See Correction Form AES 10 for corrected deficiencies. Number attached:
'' I hereby certify that the fire protection equipment listed above has been fully inspected,tested,and maintained on this date by
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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 `Wyatt C.
Signature I t7. Date 03/13/24