HomeMy WebLinkAboutFAI20-0020 010-250-006 CF FS 3-13-24 Inspection, Testing, and Maintenance Cover "'' - -
,xW Wuswg,u iw W �,WW,u NFPA25 as amended by CCR, Title 19
Property Information: _ .
Name: Orchard Hospital Occupancy/Use: _
Address: 240 Spruce St Construction Type: OF i
�� O(
City: Gridley No. Stories: 1 co/ z%
ZIP: 95948 Year Constructed: 9� -. ,P))
Contact:
Mike Newton ��` RE. P�3Z'
�1111
Telephone: 701-7681
Contractor Information: Number of System Risers
Name: Voltage Specialists Copy sent to:
Address: 370 Apple Lane [1 Owner Date: 03/13/24
City: Paradise ElFire AHJ Date:
State: California [1]Contractor Date:
(530) 624-4514 NOTES:
Telephone: 1)For specific inspection, testing, and maintenance
880862 requirements and information, see NFPA 25,2011
`'"'CA License#: Edition as amended by California Code of Regulations,
Title 19,§901 to§906.
Job#:
2) Inspection items may be performed by the owner in
Performed by: Wyatt C. accordance with California Code of Regulations,Title 19,
§904.1(a)
Check box for each system inspected and enter tie number of forms used for inspection.
Check boxes(Fail or Pass)to indicate status of inspected system at end of inspection.
N PA 25
Forms Included with this Report Chapter Number of Forms N/A Fail* ,s.
❑✓ Automatic Sprinkler System 5 0 ❑ ❑ 0
El Standpipe and Hose System I 6 I 0 I ❑ I ILI
❑ Private Water Supply System I 7 I 0 I ❑ I ❑ ICI
El Fire Pump I 8 I 0 ID I ❑ IEl
❑ Water Storage Tank 9 I 0 I ❑ I ❑ I ❑
❑ Water Spray System 10 I 0 ❑ I ❑ I ❑
❑ Foam Water Sprinkler System 11 0 IE I ❑ I
O Water Mist System 12 0 I ❑ I ❑ I ❑
IConcerns that are not deficiencies (i.e. Non-Sprinklered Areas) J ❑ Yes RI No
See"Deficiencies and Comments"section at end of each respective form.
Wet Pipe California Code of Regulations -Title 19 Quarterly and 1 of 3
Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report
Property Information ZZZA,
P Y ,�(,- o Contractor or Licensed Owner Information
7,/ ' ^�\9
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ing Name Orchard Hospital y((` v 0 Name Voltage Specialists
Address 240 Spruce St 14, +'^'",'Q r Address 370 Apple Lane
t.4 e MP - City Paradise St. CA Zip 95969
!City Gridley License# 880862 ,Phone 530-362-2609
k !Contact Person ❑ SFM !Job#1-432
Mike Newton ❑✓ CSLB 'Misc.
Riser Information
N-,q i,1 bti. ', Main Drain Test (Annual)
Risoer Location Riser Main Drain Initial Static Residual Final Static P F N/AN
Diameter Diameter Pressure Pressure Pressure ,
1 I Outside Kitchen I 4° I 2" I I I I
I
, !
I i I I I
I I I I I I I
I 1 I I I I I
jJ This building has more than 5 risers. See additional AES 2.9 form attached Number of AES 2.9 forms attached I I
Quarter] Inspections1111141411 iktheililldI101011'll'erlazf y 1 1u llp , 111 LL F a
=Inspection T=Test M=Maintenance P=Pass F=Fail N/A=Not Applicable
s Item Description INFPA 25 CA ed. pate Date Date.__ I Date
I Reference 01/09/2.4 03/13/24 r.—
1 I Control Valves—Identification Sign 1 13.3.1 P TP1
1.2 I Control Valves—Inspection 13.3.2 P P I
1.3 I Waterflow Alarm Devices 5.2.5 P P I
1.4 I Supervisory Devices 5.2.5 P P I
1.5 I Gauges(Wet Pipe Systems) 5.2.4.1 P P I
li 1.6 I Enter Water Supply Pressure Below Riser Check 5.2.4.1 psi psil psi psi
1.7 I Enter Water Supply Pressure Above Riser Check 5.2.4.1 I psi psil psi psi
1.8 I Pressure Readings Acceptable 5.2.4.1 P P I
1.9 I Hydraulic Design Information Sign 5.2.6 P P I
(for hydraulically designed systems)
1.10 I General Information Sign 5 2 8 P P
(not required for system prior to 2007 edition of NFPA 13)
1.11 I Heat Tape 5.2.7 I N/A N/A I N/A
1.12 I Spare Sprinklers 5,2.1.4 I P P I
1.13 I Fire Department Connections 13.7 P P I
1.14 I 'Alarm Valves—Exterior Inspection 13.4.1 P P I
1.15 I Pressure Reducing Valves 13.5.1.1 J N/A N/A 1 N/A
1.16 I Backflow Preventers 13.6.1 N/A N/A I N/A
‘,411100,17 I Small Hose Connections-Hose Valve* 5.1.6, 13.5.2 13.5.5.1 N/A N/A I N/A
1.18 I PRV—Fire Sprinkler Systems 13.5.1.1 I N/A N/A I N/A
*Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II,or III
standpipe systems.
II'
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• 2 of 3
Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report
Property Information T,� F�A o+�� Contractor or Licensed Owner Information
pig'
9 Hospital /�' ''15 Name Voltage Specialists
yr
uildin Name Orchard
Address 1> (._St` QH Job#1-432
A !City Gridley `Z1�'R E NIPS
ANNUAL INSPECTION, TESTING, AND MAINTENANCE
Include ALL Quarterly Inspections
I = Inspection T =Test M=Maintenance P=Pass F=Fail N/A=Not Applicable
Item I I Description INFPA 25 CA ed. I Reference Date Comments Only I P,F,N/A
1.19 I I !Sprinklers I 5.2.1 I
1 1.20 I I 'Buildings(Freeze Protection) I 4.1.1.1 I Owner's Responsibility I N/A
1.21 I I 'Pipe and Fittings 5.2.2 I
1.22 I I 'Hangers 5.2.3 I
1.23 I I !Seismic Braces 5.2.3 I
2.1 I T Field ServicedRepo rt Test FRequiredCodeOfficial)
5.3.1
( ire results are returned from Lab
2.2 I T (RecalledIfnot Sprinklers= Title 19
present Pass; If present=Fail 904.1(c)
4.
2.3 I T !Water Flow Alarm Devices 5.3.3
90 sec. maximum - (Enter Time) 13.2.6 I 129 SeC.
2.4 I T !Main Drain Test 13.2.5
(Enter data on Page 1 of this form) 13.3.3.4
Iftior
5 I T 'Control Valve-Position 13.3.3.2 I
2.6 I T 'Control Valve—Operation 13.3.3.1 I I
2.7 I T 'Supervisory Devices 13.3.3.5 I I
ii 2.8 I T 'Backflow Preventer Assemblies 13.6.2 I N/A
2.9 I T !Smallw/PRV Hose ConnectionsoseValves " 13.5.2.3
H —Partial Flow Test 13.5.3.3 N/A
2.10 I T !PRV—Fire Sprinkler Systems 13.5.1.3 I I N/A
3.1 I M !Control Valves 13.3.4 I I
3.2 I M 'Small Hose Connections* 13.5.6.3 I I N/A
Obstruction Investigation required Yes
3.3 M (If"Yes",see Deficiencies and Comments Section 14.3
for Results.) ✓ No
I
3.4 I M 'System Returned to Service 4.5.3 EYes
No
"Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II,or III
standpipe systems.
D=Deficiency C=Comment (Indicate type)
° + D C i Deficiencies and Comments
o indicate all equipment,d ances and`�-�-` ' �. �„ �` � ^, �t"�� � p l.>aRs that were repaired or replaced
I �i.
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qp°Ip'I �. i i. .. 3 0 3
Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report
OF Cq�/� t Contractor or Licensed Owner Information
11
Property Information ���r ,,opr
uilding Name Orchard Hospital ( C� ;k3 )5 Name Voltage Specialists
Address r9, ,� .'� Job# 1-432
(City Gridley `���E M
D=Deficiency C=Comment (Indicate type)
Item Date Riser D C Deficiencies and Comments(cont.)
Indicate Ali„fit{rntunent devices and part i riIot Ittilt,op.n...1 o,r I?it (
III..____
1111
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El Check here if additional Deficiencies and Comments are listed on Form AES9 Number attached:
❑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
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.
Check box if Annual Inspection,Testing&Maintenance Items are Completed in the Indicated Quarter
Quarter 1st - ❑✓ Annual 2nd - ❑ Annual 3rd - ❑ Annual 4th - ❑ Annual
Date 01/09/24 03/13/24
Print Name Mat Machado Wyatt C.
.* Signature fr---
L
VOIAG $PECIALISTS '' `f
Tsib.�370 Apple Lane, Paradise, C95969 Phone 530-624-4514
www.VoltageSpecialists.com
State of Calif Fire/Life Safety#113568 Calif C10/C16 880862
NICET#87630 DIR 10000141915 Local 340
Live Scanned & Fire Life Safety Certified Personnel
EP 2 - Tamper Switches & Water Flows
Date: 3/13/24 Wyatt C.
Inspector:
Location: Orchard Hospital Address: 240 Spruce Street, Gridley
Riser
Time for W/F to
Location # Device Type Report to Panel Pass Fail Notes
I I
Outside Medical Records I WF-1 Water Flow 133 sec. X
On Riser Outside Kitchen ITS-1 Tamper Switch I 1 turn X
Comments/Notes
EC.02.03.05 EP 25
Testing Activity:EP 2:Tampers and Flow Devices
Required Frequency of activity:Quarterly
For additional guidance,reference NFPA standard(s):NFPA 72-2016 Edition;Table 14.4.3.2;
NFPA 25-Table 13.1.1.2;Reference 13.2.6
3/13/24
CUSTOMER SIGNATURE DATE TECH SIGNATURE
VOLITAGEPECIALISTS
370 Apple Lane, Paradise, CA 95969
www.VoltageSpecialists.com
EP 10 - Quarterly Fire Department Inspections
Date: 3/13/24 Inspector: Wyatt C.
Location: Orchard Hospital Address: 240 Spruce Street,Gridley
FDC Riser
Location # Pass Fail Note # Cause of Failure
Outside Kitchen X
Comments/Notes
EC.02.03.05 EP 25
Testing Activity:EP 10:Fire Department Connections
Required Frequency of activity:Quarterly
For additional guidance referenced NFPA standard(s):NFPA 25-2013 CA Edition;Table 13.1.1.2 Reference 13.7.1
Numov
**-""°..°°'
3/13/24
CUSTOMER SIGNATURE DATE TECH SIGNATURE