Fillable BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

Fill Online, Printable, Fillable, Blank BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland) Form

Use Fill to complete blank online CITY OF OAKLAND (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

On average this form takes 21 minutes to complete

The BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland) form is 1 page long and contains:

  • 4 signatures
  • 50 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
CUSTOMER
DEVICE ID
JOB NUMBER
MAILING ADDRESS
SERVICE LOCATION METER NUMBER
DATE OF TEST TIME A.M. SUPPLY PRESSURE AIR GAP (2 X SUPPLY DIAM.) PASS
P.M. ______________ LBS. SUPPLY _____________ IN. GAP _________________ IN. FAIL
TYPE OF ASSEMBLY MANUFACTURER MODEL SIZE SERIAL NUMBER
HEIGHT OFF FLOOR PROTECTION FROM: COMMENTS: NEW INSTALLATION
_____________________ (IN/FT) FREEZING YES NO FLOODING YES NO YES NO
regulations requires testers to report results of tests and inspections to the customer and the water supplier.
WE ARE NOT RESPONSIBLE AFTER ASSEMBLY TESTED.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
TESTED BY (PRINT) (SIGNATURE) REPAIRED BY (PRINT) (SIGNATURE)
COMPANY FINAL TEST BY (PRINT) (SIGNATURE)
CERTIFICATION NUMBER AND EXPIRATION DATE OWNER OR OWNER’S REPRESENTATIVE DATE
APPLICATION:
COMMERCIAL
FIRE LINE
IRRIGATION
OTHER (EXPLAIN
COMMENTS:
INITIAL TEST Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY: 
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure 
NO. 2 SHUTOFF VALVE leak tight 
1ST CHECK held in
direction of flow
_____ *PSID (5 PSID or more) 
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
NOTE: Failure of any of the above items requires repair.
INITIAL TEST Passed Failed
DOUBLE CHECK VALVE ASSEMBLY: 
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
NOTE: Failure of any of the above items requires repair.
FINAL TEST AFTER REPAIR Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY:
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure
NO. 2 SHUTOFF VALVE leak tight
1ST CHECK held in
direction of flow
_____ PSID (5 PSID or more)
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
*Pounds per Square Inch Differential
FINAL TEST AFTER REPAIR Passed Failed
DOUBLE CHECK VALVE ASSEMBLY:
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more)
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more)
NOTE: Failure of any of the above items requires repair.
TOLL FREE
(888) 4-MARMIC (627642)
Holt High School
21771021
600 Campus Drive
Room 120 Auditorium
DC
Febco
805Y
6"
3'
1.4
1.2
Tony Witt
Marmic Fire and Safety
34-11613
06/14/2021 08:30am CDT
WENTZVILLE
MO
63385
✔
✔
✔
✔
✔
✔
✔
06/14/2021 08:30am CDT
St. Louis
11694 Lackland Road
MO
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
CUSTOMER
DEVICE ID
JOB NUMBER
MAILING ADDRESS
SERVICE LOCATION METER NUMBER
DATE OF TEST TIME A.M. SUPPLY PRESSURE AIR GAP (2 X SUPPLY DIAM.) PASS
P.M. ______________ LBS. SUPPLY _____________ IN. GAP _________________ IN. FAIL
TYPE OF ASSEMBLY MANUFACTURER MODEL SIZE SERIAL NUMBER
HEIGHT OFF FLOOR PROTECTION FROM: COMMENTS: NEW INSTALLATION
_____________________ (IN/FT) FREEZING YES NO FLOODING YES NO YES NO
regulations requires testers to report results of tests and inspections to the customer and the water supplier.
WE ARE NOT RESPONSIBLE AFTER ASSEMBLY TESTED.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
TESTED BY (PRINT) (SIGNATURE) REPAIRED BY (PRINT) (SIGNATURE)
COMPANY FINAL TEST BY (PRINT) (SIGNATURE)
CERTIFICATION NUMBER AND EXPIRATION DATE OWNER OR OWNER’S REPRESENTATIVE DATE
APPLICATION:
COMMERCIAL
FIRE LINE
IRRIGATION
OTHER (EXPLAIN
COMMENTS:
INITIAL TEST Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY: 
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure 
NO. 2 SHUTOFF VALVE leak tight 
1ST CHECK held in
direction of flow
_____ *PSID (5 PSID or more) 
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
NOTE: Failure of any of the above items requires repair.
INITIAL TEST Passed Failed
DOUBLE CHECK VALVE ASSEMBLY: 
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
NOTE: Failure of any of the above items requires repair.
FINAL TEST AFTER REPAIR Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY:
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure
NO. 2 SHUTOFF VALVE leak tight
1ST CHECK held in
direction of flow
_____ PSID (5 PSID or more)
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
*Pounds per Square Inch Differential
FINAL TEST AFTER REPAIR Passed Failed
DOUBLE CHECK VALVE ASSEMBLY:
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more)
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more)
NOTE: Failure of any of the above items requires repair.
TOLL FREE
(888) 4-MARMIC (627642)
HOLT HIGH SCHOOL
21771021
600 CAMPUS DRIVE
Upstairs Mechanical Room
DC
Ames
Colt 200
6"
3'
1.5
1.4
Tony Witt
Marmic Fire and Safety
34-11613
06/14/2021 08:30am CDT
WENTZVILLE
MO
63385
✔
✔
✔
✔
✔
✔
✔
06/14/2021 08:30am CDT
St. Louis
11694 Lackland Road
MO
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
CUSTOMER
DEVICE ID
JOB NUMBER
MAILING ADDRESS
SERVICE LOCATION METER NUMBER
DATE OF TEST TIME A.M. SUPPLY PRESSURE AIR GAP (2 X SUPPLY DIAM.) PASS
P.M. ______________ LBS. SUPPLY _____________ IN. GAP _________________ IN. FAIL
TYPE OF ASSEMBLY MANUFACTURER MODEL SIZE SERIAL NUMBER
HEIGHT OFF FLOOR PROTECTION FROM: COMMENTS: NEW INSTALLATION
_____________________ (IN/FT) FREEZING YES NO FLOODING YES NO YES NO
regulations requires testers to report results of tests and inspections to the customer and the water supplier.
WE ARE NOT RESPONSIBLE AFTER ASSEMBLY TESTED.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
TESTED BY (PRINT) (SIGNATURE) REPAIRED BY (PRINT) (SIGNATURE)
COMPANY FINAL TEST BY (PRINT) (SIGNATURE)
CERTIFICATION NUMBER AND EXPIRATION DATE OWNER OR OWNER’S REPRESENTATIVE DATE
APPLICATION:
COMMERCIAL
FIRE LINE
IRRIGATION
OTHER (EXPLAIN
COMMENTS:
INITIAL TEST Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY: 
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure 
NO. 2 SHUTOFF VALVE leak tight 
1ST CHECK held in
direction of flow
_____ *PSID (5 PSID or more) 
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
NOTE: Failure of any of the above items requires repair.
INITIAL TEST Passed Failed
DOUBLE CHECK VALVE ASSEMBLY: 
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
NOTE: Failure of any of the above items requires repair.
FINAL TEST AFTER REPAIR Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY:
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure
NO. 2 SHUTOFF VALVE leak tight
1ST CHECK held in
direction of flow
_____ PSID (5 PSID or more)
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
*Pounds per Square Inch Differential
FINAL TEST AFTER REPAIR Passed Failed
DOUBLE CHECK VALVE ASSEMBLY:
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more)
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more)
NOTE: Failure of any of the above items requires repair.
TOLL FREE
(888) 4-MARMIC (627642)
WENTZVILLE SCHOOLS ADMIN BUILDING
21771021
280 INTERSTATE DR
Kevin Hergenroeder, Michael Reinkemeyer, Tony Witt
Marmic Fire and Safety
06/14/2021 08:30am CDT
WENTZVILLE
MO
63385
06/14/2021 08:30am CDT
St. Louis
11694 Lackland Road
MO
BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT
CUSTOMER
DEVICE ID
JOB NUMBER
MAILING ADDRESS
SERVICE LOCATION METER NUMBER
DATE OF TEST TIME A.M. SUPPLY PRESSURE AIR GAP (2 X SUPPLY DIAM.) PASS
P.M. ______________ LBS. SUPPLY _____________ IN. GAP _________________ IN. FAIL
TYPE OF ASSEMBLY MANUFACTURER MODEL SIZE SERIAL NUMBER
HEIGHT OFF FLOOR PROTECTION FROM: COMMENTS: NEW INSTALLATION
_____________________ (IN/FT) FREEZING YES NO FLOODING YES NO YES NO
regulations requires testers to report results of tests and inspections to the customer and the water supplier.
WE ARE NOT RESPONSIBLE AFTER ASSEMBLY TESTED.
THE ABOVE REPORT IS CERTIFIED TO BE TRUE, ACCURATE AND COMPLETE
TESTED BY (PRINT) (SIGNATURE) REPAIRED BY (PRINT) (SIGNATURE)
COMPANY FINAL TEST BY (PRINT) (SIGNATURE)
CERTIFICATION NUMBER AND EXPIRATION DATE OWNER OR OWNER’S REPRESENTATIVE DATE
APPLICATION:
COMMERCIAL
FIRE LINE
IRRIGATION
OTHER (EXPLAIN
COMMENTS:
INITIAL TEST Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY: 
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure 
NO. 2 SHUTOFF VALVE leak tight 
1ST CHECK held in
direction of flow
_____ *PSID (5 PSID or more) 
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
NOTE: Failure of any of the above items requires repair.
INITIAL TEST Passed Failed
DOUBLE CHECK VALVE ASSEMBLY: 
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more) 
NOTE: Failure of any of the above items requires repair.
FINAL TEST AFTER REPAIR Passed Failed
REDUCED PRESSURE PRINCIPLE ASSEMBLY:
RELIEF VALVE
OPENED AT
_____ *PSID (2 PSID or more)
2ND CHECK held back pressure
NO. 2 SHUTOFF VALVE leak tight
1ST CHECK held in
direction of flow
_____ PSID (5 PSID or more)
DIFFERENCE
(1st check - relief)
_____ PSID (3 PSID or more)
*Pounds per Square Inch Differential
FINAL TEST AFTER REPAIR Passed Failed
DOUBLE CHECK VALVE ASSEMBLY:
1ST CHECK held in
direction of flow
_____ PSID (1 PSID or more)
2ND CHECK held in
direction of flow
_____ PSID (1 PSID or more)
NOTE: Failure of any of the above items requires repair.
TOLL FREE
(888) 4-MARMIC (627642)
WENTZVILLE SCHOOLS ADMIN BUILDING
21771021
280 INTERSTATE DR
Kevin Hergenroeder, Michael Reinkemeyer, Tony Witt
Marmic Fire and Safety
06/14/2021 08:30am CDT
WENTZVILLE
MO
63385
06/14/2021 08:30am CDT
St. Louis
11694 Lackland Road
MO
1-
888-462-7642
Report of Inspection &
Testing of
Wet Pipe Fire Protection
S
ystems Annual
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL
BLANKS TO BE FILLED
CUSTOMER
SYSTEM ID
ADDRESS:
Inspector Name:
Date:
I acknowledge that the listed deficiencies have been discussed with me and that I am requesting a quote for the repair of said deficiencies.
Owner/Designated Representative
All “NO” answers must be
fully explained.
Inspector’s Initial
Owner/Designated Rep. Initial
Date
Annual Report of Inspection
of Wet Sprinkler System
Annual Testing Requirements
for Wet Sprinkler System
Annual Report of Inspection
of Wet Sprinkler System
YN/AN
5.2 Hydraulic nameplate attached
5.2 Exterior alarms properly identified
13.1 FDC plainly visible
13.1 FDC easily accessible
13.1 FDC swivels in non-binding rotation
13.1 Caps/plugs in place
13.1 Gaskets/signs in place
13.1 FDC Ball drip drain drip free
5.1 Alarm panel clear
System in Service
Comments:
5.2 Sprinkler supply gauge psi
5.2Sprinkler supply gauge ___ main drain flow psi
5.2 Sprinkler system gauge psi
5.2 Sprinkler system with main drain flow psi
Y N/A N
5.3 Interior building alarms operating
5.3 Exterior alarms operating
5.3 Inspector’s test flow psi
5.3 Time to ring alarm from
alarm check valve min sec
5.3 Time to ring alarm from
flow switch min sec
5.3 Time to ring alarm from
pressure switch min sec
Y N/A N
5.3 Gauges appear operating properly
5.1 Did alarm supervisory company receive
signal properly?
5.1 Did alarm panel reset properly?
Comments:
Y N/A N
4.1 Prior to freezing season, owner is
responsible for building to be in secure
condition and properly heated.
5.2 Visual Inspection: hanger/seismic
bracing appears attached and secure.
5.2 Visual Inspection: “exposed” piping
appears in good condition.
5.2
Piping appears free of mechanical damage.
5.2 Piping appears free of leakage.
5.2 Piping appears free of corrosion.
5.2 Piping appears properly aligned.
5.2 Piping appears free of external loads.
5.2 Sprinklers appear free of corrosion.
5.2 Sprinklers appear properly positioned.
5.2 Sprinklers appear properly spaced.
5.2
Sprinklers appear free of foreign material.
5.2 Sprinkler spray patterns appear free of
obstructions.
Comments:
Annual Testing & Maintenance Tasks that are in Addition to
Other Frequency Tasks - For Wet Sprinkler System
Y N/A N
13.3 Control valve lubricated
13.3 Control valve operated to closed
position and returned to open position
13.3 Control valve locked/tampered open
13.3 Backflow assembly control valves
operated & returned to open position
13.3 Post indicator valve operated with
_____ number of turns recorded
13.3 Post indicator valve returned to open
position
(All above listed control valves to be left 1/4 turn from wide open.)
5.3 Antifreeze solution checked to provide
adequate freeze protection:
(protection temp: _______ ° F)
Testing Frequency Items of 5 Years or Greater
14.3 Internal Inspection last date (5 years) ________
13.1 Alarm check valve
6.1 Flow tested pressure regulating control
valves***
Alarm Valve Info Y N/A N
Make
Model
Size Date
13.4 Check valve
13.4 Strainers
13.4 Filters
13.4 Trim orifices
5.3 Gauge maintenance: date last tested (5 years) _____
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test
5.3 (5 years)
High temp. date ________________
5.3 (20 years, then 10 years thereafter)
Fast response date ______________
5.3 Residential head (20 years)
5.3 (50 years, then 10 years thereafter)
Standard sprinkler date __________
Comments:
(Description of this form: These tasks are in addition to the monthly and quar-
terly tasks. Complete the monthly and quarterly reports AND this report as re-
quired for a total annual report of inspection. Visual inspection is defined as what
can be observed from the floor level by an inspector. The use of binoculars is
recommended for visual inspections in high buildings.)
JOB #
1985
06/14/2021 08:30am CDT
Holt High school
Kevin Hergenroeder, Tony Witt
Riser 1 Lower Room
06/14/2021 08:30am CDT
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
75
75
65
65
36
Shotgun
1985
1985
✔
✔
21771021
600 CAMPUS DRIVE
WENTZVILLE
MO
11694 Lackland Road
St. Louis
MO
65
1-
888-462-7642
Report of Inspection &
Testing of
Wet Pipe Fire Protection
S
ystems Annual
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL
BLANKS TO BE FILLED
CUSTOMER
SYSTEM ID
ADDRESS:
Inspector Name:
Date:
I acknowledge that the listed deficiencies have been discussed with me and that I am requesting a quote for the repair of said deficiencies.
Owner/Designated Representative
All “NO” answers must be
fully explained.
Inspector’s Initial
Owner/Designated Rep. Initial
Date
Annual Report of Inspection
of Wet Sprinkler System
Annual Testing Requirements
for Wet Sprinkler System
Annual Report of Inspection
of Wet Sprinkler System
YN/AN
5.2 Hydraulic nameplate attached
5.2 Exterior alarms properly identified
13.1 FDC plainly visible
13.1 FDC easily accessible
13.1 FDC swivels in non-binding rotation
13.1 Caps/plugs in place
13.1 Gaskets/signs in place
13.1 FDC Ball drip drain drip free
5.1 Alarm panel clear
System in Service
Comments:
5.2 Sprinkler supply gauge psi
5.2Sprinkler supply gauge ___ main drain flow psi
5.2 Sprinkler system gauge psi
5.2 Sprinkler system with main drain flow psi
Y N/A N
5.3 Interior building alarms operating
5.3 Exterior alarms operating
5.3 Inspector’s test flow psi
5.3 Time to ring alarm from
alarm check valve min sec
5.3 Time to ring alarm from
flow switch min sec
5.3 Time to ring alarm from
pressure switch min sec
Y N/A N
5.3 Gauges appear operating properly
5.1 Did alarm supervisory company receive
signal properly?
5.1 Did alarm panel reset properly?
Comments:
Y N/A N
4.1 Prior to freezing season, owner is
responsible for building to be in secure
condition and properly heated.
5.2 Visual Inspection: hanger/seismic
bracing appears attached and secure.
5.2 Visual Inspection: “exposed” piping
appears in good condition.
5.2
Piping appears free of mechanical damage.
5.2 Piping appears free of leakage.
5.2 Piping appears free of corrosion.
5.2 Piping appears properly aligned.
5.2 Piping appears free of external loads.
5.2 Sprinklers appear free of corrosion.
5.2 Sprinklers appear properly positioned.
5.2 Sprinklers appear properly spaced.
5.2
Sprinklers appear free of foreign material.
5.2 Sprinkler spray patterns appear free of
obstructions.
Comments:
Annual Testing & Maintenance Tasks that are in Addition to
Other Frequency Tasks - For Wet Sprinkler System
Y N/A N
13.3 Control valve lubricated
13.3 Control valve operated to closed
position and returned to open position
13.3 Control valve locked/tampered open
13.3 Backflow assembly control valves
operated & returned to open position
13.3 Post indicator valve operated with
_____ number of turns recorded
13.3 Post indicator valve returned to open
position
(All above listed control valves to be left 1/4 turn from wide open.)
5.3 Antifreeze solution checked to provide
adequate freeze protection:
(protection temp: _______ ° F)
Testing Frequency Items of 5 Years or Greater
14.3 Internal Inspection last date (5 years) ________
13.1 Alarm check valve
6.1 Flow tested pressure regulating control
valves***
Alarm Valve Info Y N/A N
Make
Model
Size Date
13.4 Check valve
13.4 Strainers
13.4 Filters
13.4 Trim orifices
5.3 Gauge maintenance: date last tested (5 years) _____
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test
5.3 (5 years)
High temp. date ________________
5.3 (20 years, then 10 years thereafter)
Fast response date ______________
5.3 Residential head (20 years)
5.3 (50 years, then 10 years thereafter)
Standard sprinkler date __________
Comments:
(Description of this form: These tasks are in addition to the monthly and quar-
terly tasks. Complete the monthly and quarterly reports AND this report as re-
quired for a total annual report of inspection. Visual inspection is defined as what
can be observed from the floor level by an inspector. The use of binoculars is
recommended for visual inspections in high buildings.)
JOB #
1985
06/14/2021 08:30am CDT
HILT HIGH SCHOOL
Kevin Hergenroeder, Tony Witt
Riser 2 2nd floor classroom
06/14/2021 08:30am CDT
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
75
75
65
65
45
Shotgun
1985
1985
✔
✔
21771021
600 CAMPUS DRIVE
WENTZVILLE
MO
11694 Lackland Road
St. Louis
MO
65
1-
888-462-7642
Report of Inspection &
Testing of
Wet Pipe Fire Protection
S
ystems Annual
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL
BLANKS TO BE FILLED
CUSTOMER
SYSTEM ID
ADDRESS:
Inspector Name:
Date:
I acknowledge that the listed deficiencies have been discussed with me and that I am requesting a quote for the repair of said deficiencies.
Owner/Designated Representative
All “NO” answers must be
fully explained.
Inspector’s Initial
Owner/Designated Rep. Initial
Date
Annual Report of Inspection
of Wet Sprinkler System
Annual Testing Requirements
for Wet Sprinkler System
Annual Report of Inspection
of Wet Sprinkler System
YN/AN
5.2 Hydraulic nameplate attached
5.2 Exterior alarms properly identified
13.1 FDC plainly visible
13.1 FDC easily accessible
13.1 FDC swivels in non-binding rotation
13.1 Caps/plugs in place
13.1 Gaskets/signs in place
13.1 FDC Ball drip drain drip free
5.1 Alarm panel clear
System in Service
Comments:
5.2 Sprinkler supply gauge psi
5.2Sprinkler supply gauge ___ main drain flow psi
5.2 Sprinkler system gauge psi
5.2 Sprinkler system with main drain flow psi
Y N/A N
5.3 Interior building alarms operating
5.3 Exterior alarms operating
5.3 Inspector’s test flow psi
5.3 Time to ring alarm from
alarm check valve min sec
5.3 Time to ring alarm from
flow switch min sec
5.3 Time to ring alarm from
pressure switch min sec
Y N/A N
5.3 Gauges appear operating properly
5.1 Did alarm supervisory company receive
signal properly?
5.1 Did alarm panel reset properly?
Comments:
Y N/A N
4.1 Prior to freezing season, owner is
responsible for building to be in secure
condition and properly heated.
5.2 Visual Inspection: hanger/seismic
bracing appears attached and secure.
5.2 Visual Inspection: “exposed” piping
appears in good condition.
5.2
Piping appears free of mechanical damage.
5.2 Piping appears free of leakage.
5.2 Piping appears free of corrosion.
5.2 Piping appears properly aligned.
5.2 Piping appears free of external loads.
5.2 Sprinklers appear free of corrosion.
5.2 Sprinklers appear properly positioned.
5.2 Sprinklers appear properly spaced.
5.2
Sprinklers appear free of foreign material.
5.2 Sprinkler spray patterns appear free of
obstructions.
Comments:
Annual Testing & Maintenance Tasks that are in Addition to
Other Frequency Tasks - For Wet Sprinkler System
Y N/A N
13.3 Control valve lubricated
13.3 Control valve operated to closed
position and returned to open position
13.3 Control valve locked/tampered open
13.3 Backflow assembly control valves
operated & returned to open position
13.3 Post indicator valve operated with
_____ number of turns recorded
13.3 Post indicator valve returned to open
position
(All above listed control valves to be left 1/4 turn from wide open.)
5.3 Antifreeze solution checked to provide
adequate freeze protection:
(protection temp: _______ ° F)
Testing Frequency Items of 5 Years or Greater
14.3 Internal Inspection last date (5 years) ________
13.1 Alarm check valve
6.1 Flow tested pressure regulating control
valves***
Alarm Valve Info Y N/A N
Make
Model
Size Date
13.4 Check valve
13.4 Strainers
13.4 Filters
13.4 Trim orifices
5.3 Gauge maintenance: date last tested (5 years) _____
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test
5.3 (5 years)
High temp. date ________________
5.3 (20 years, then 10 years thereafter)
Fast response date ______________
5.3 Residential head (20 years)
5.3 (50 years, then 10 years thereafter)
Standard sprinkler date __________
Comments:
(Description of this form: These tasks are in addition to the monthly and quar-
terly tasks. Complete the monthly and quarterly reports AND this report as re-
quired for a total annual report of inspection. Visual inspection is defined as what
can be observed from the floor level by an inspector. The use of binoculars is
recommended for visual inspections in high buildings.)
JOB #
1985
06/14/2021 08:30am CDT
HOLT HIGH SCHOOL
Kevin Hergenroeder, Tony Witt
Riser 3 1st floor classroom addition
06/14/2021 08:30am CDT
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
75
75
60
60
42
Shotgun
1985
1985
✔
✔
21771021
600 campus drive
WENTZVILLE
MO
11694 Lackland Road
St. Louis
MO
60
1-
888-462-7642
Report of Inspection &
Testing of
Wet Pipe Fire Protection
S
ystems Annual
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL
BLANKS TO BE FILLED
CUSTOMER
SYSTEM ID
ADDRESS:
Inspector Name:
Date:
I acknowledge that the listed deficiencies have been discussed with me and that I am requesting a quote for the repair of said deficiencies.
Owner/Designated Representative
All “NO” answers must be
fully explained.
Inspector’s Initial
Owner/Designated Rep. Initial
Date
Annual Report of Inspection
of Wet Sprinkler System
Annual Testing Requirements
for Wet Sprinkler System
Annual Report of Inspection
of Wet Sprinkler System
YN/AN
5.2 Hydraulic nameplate attached
5.2 Exterior alarms properly identified
13.1 FDC plainly visible
13.1 FDC easily accessible
13.1 FDC swivels in non-binding rotation
13.1 Caps/plugs in place
13.1 Gaskets/signs in place
13.1 FDC Ball drip drain drip free
5.1 Alarm panel clear
System in Service
Comments:
5.2 Sprinkler supply gauge psi
5.2Sprinkler supply gauge ___ main drain flow psi
5.2 Sprinkler system gauge psi
5.2 Sprinkler system with main drain flow psi
Y N/A N
5.3 Interior building alarms operating
5.3 Exterior alarms operating
5.3 Inspector’s test flow psi
5.3 Time to ring alarm from
alarm check valve min sec
5.3 Time to ring alarm from
flow switch min sec
5.3 Time to ring alarm from
pressure switch min sec
Y N/A N
5.3 Gauges appear operating properly
5.1 Did alarm supervisory company receive
signal properly?
5.1 Did alarm panel reset properly?
Comments:
Y N/A N
4.1 Prior to freezing season, owner is
responsible for building to be in secure
condition and properly heated.
5.2 Visual Inspection: hanger/seismic
bracing appears attached and secure.
5.2 Visual Inspection: “exposed” piping
appears in good condition.
5.2
Piping appears free of mechanical damage.
5.2 Piping appears free of leakage.
5.2 Piping appears free of corrosion.
5.2 Piping appears properly aligned.
5.2 Piping appears free of external loads.
5.2 Sprinklers appear free of corrosion.
5.2 Sprinklers appear properly positioned.
5.2 Sprinklers appear properly spaced.
5.2
Sprinklers appear free of foreign material.
5.2 Sprinkler spray patterns appear free of
obstructions.
Comments:
Annual Testing & Maintenance Tasks that are in Addition to
Other Frequency Tasks - For Wet Sprinkler System
Y N/A N
13.3 Control valve lubricated
13.3 Control valve operated to closed
position and returned to open position
13.3 Control valve locked/tampered open
13.3 Backflow assembly control valves
operated & returned to open position
13.3 Post indicator valve operated with
_____ number of turns recorded
13.3 Post indicator valve returned to open
position
(All above listed control valves to be left 1/4 turn from wide open.)
5.3 Antifreeze solution checked to provide
adequate freeze protection:
(protection temp: _______ ° F)
Testing Frequency Items of 5 Years or Greater
14.3 Internal Inspection last date (5 years) ________
13.1 Alarm check valve
6.1 Flow tested pressure regulating control
valves***
Alarm Valve Info Y N/A N
Make
Model
Size Date
13.4 Check valve
13.4 Strainers
13.4 Filters
13.4 Trim orifices
5.3 Gauge maintenance: date last tested (5 years) _____
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test
5.3 (5 years)
High temp. date ________________
5.3 (20 years, then 10 years thereafter)
Fast response date ______________
5.3 Residential head (20 years)
5.3 (50 years, then 10 years thereafter)
Standard sprinkler date __________
Comments:
(Description of this form: These tasks are in addition to the monthly and quar-
terly tasks. Complete the monthly and quarterly reports AND this report as re-
quired for a total annual report of inspection. Visual inspection is defined as what
can be observed from the floor level by an inspector. The use of binoculars is
recommended for visual inspections in high buildings.)
JOB #
2006
06/14/2021 08:30am CDT
Holt High SCHOOL
Kevin Hergenroeder, Tony Witt
Riser 1 Lowe Level
06/14/2021 08:30am CDT
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
75
75
65
65
38
Shotgun
2006
2006
✔
✔
21771021
600 CAMPUS DRIVE
WENTZVILLE
MO
11694 Lackland Road
St. Louis
MO
65
1-
888-462-7642
Report of Inspection &
Testing of
Wet Pipe Fire Protection
S
ystems Annual
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL
BLANKS TO BE FILLED
CUSTOMER
SYSTEM ID
ADDRESS:
Inspector Name:
Date:
I acknowledge that the listed deficiencies have been discussed with me and that I am requesting a quote for the repair of said deficiencies.
Owner/Designated Representative
All “NO” answers must be
fully explained.
Inspector’s Initial
Owner/Designated Rep. Initial
Date
Annual Report of Inspection
of Wet Sprinkler System
Annual Testing Requirements
for Wet Sprinkler System
Annual Report of Inspection
of Wet Sprinkler System
YN/AN
5.2 Hydraulic nameplate attached
5.2 Exterior alarms properly identified
13.1 FDC plainly visible
13.1 FDC easily accessible
13.1 FDC swivels in non-binding rotation
13.1 Caps/plugs in place
13.1 Gaskets/signs in place
13.1 FDC Ball drip drain drip free
5.1 Alarm panel clear
System in Service
Comments:
5.2 Sprinkler supply gauge psi
5.2Sprinkler supply gauge ___ main drain flow psi
5.2 Sprinkler system gauge psi
5.2 Sprinkler system with main drain flow psi
Y N/A N
5.3 Interior building alarms operating
5.3 Exterior alarms operating
5.3 Inspector’s test flow psi
5.3 Time to ring alarm from
alarm check valve min sec
5.3 Time to ring alarm from
flow switch min sec
5.3 Time to ring alarm from
pressure switch min sec
Y N/A N
5.3 Gauges appear operating properly
5.1 Did alarm supervisory company receive
signal properly?
5.1 Did alarm panel reset properly?
Comments:
Y N/A N
4.1 Prior to freezing season, owner is
responsible for building to be in secure
condition and properly heated.
5.2 Visual Inspection: hanger/seismic
bracing appears attached and secure.
5.2 Visual Inspection: “exposed” piping
appears in good condition.
5.2
Piping appears free of mechanical damage.
5.2 Piping appears free of leakage.
5.2 Piping appears free of corrosion.
5.2 Piping appears properly aligned.
5.2 Piping appears free of external loads.
5.2 Sprinklers appear free of corrosion.
5.2 Sprinklers appear properly positioned.
5.2 Sprinklers appear properly spaced.
5.2
Sprinklers appear free of foreign material.
5.2 Sprinkler spray patterns appear free of
obstructions.
Comments:
Annual Testing & Maintenance Tasks that are in Addition to
Other Frequency Tasks - For Wet Sprinkler System
Y N/A N
13.3 Control valve lubricated
13.3 Control valve operated to closed
position and returned to open position
13.3 Control valve locked/tampered open
13.3 Backflow assembly control valves
operated & returned to open position
13.3 Post indicator valve operated with
_____ number of turns recorded
13.3 Post indicator valve returned to open
position
(All above listed control valves to be left 1/4 turn from wide open.)
5.3 Antifreeze solution checked to provide
adequate freeze protection:
(protection temp: _______ ° F)
Testing Frequency Items of 5 Years or Greater
14.3 Internal Inspection last date (5 years) ________
13.1 Alarm check valve
6.1 Flow tested pressure regulating control
valves***
Alarm Valve Info Y N/A N
Make
Model
Size Date
13.4 Check valve
13.4 Strainers
13.4 Filters
13.4 Trim orifices
5.3 Gauge maintenance: date last tested (5 years) _____
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test
5.3 (5 years)
High temp. date ________________
5.3 (20 years, then 10 years thereafter)
Fast response date ______________
5.3 Residential head (20 years)
5.3 (50 years, then 10 years thereafter)
Standard sprinkler date __________
Comments:
(Description of this form: These tasks are in addition to the monthly and quar-
terly tasks. Complete the monthly and quarterly reports AND this report as re-
quired for a total annual report of inspection. Visual inspection is defined as what
can be observed from the floor level by an inspector. The use of binoculars is
recommended for visual inspections in high buildings.)
JOB #
2006
06/14/2021 08:30am CDT
Holt High school
Kevin Hergenroeder, Tony Witt
Riser 2 Upper Level
06/14/2021 08:30am CDT
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
75
75
65
65
46
Shotgun
2006
2016
✔
✔
21771021
600 Campus Drive
WENTZVILLE
MO
11694 Lackland Road
St. Louis
MO
65
1-
888-462-7642
Report of Inspection &
Testing of
Wet Pipe Fire Protection
S
ystems Annual
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL
BLANKS TO BE FILLED
CUSTOMER
SYSTEM ID
ADDRESS:
Inspector Name:
Date:
I acknowledge that the listed deficiencies have been discussed with me and that I am requesting a quote for the repair of said deficiencies.
Owner/Designated Representative
All “NO” answers must be
fully explained.
Inspector’s Initial
Owner/Designated Rep. Initial
Date
Annual Report of Inspection
of Wet Sprinkler System
Annual Testing Requirements
for Wet Sprinkler System
Annual Report of Inspection
of Wet Sprinkler System
YN/AN
5.2 Hydraulic nameplate attached
5.2 Exterior alarms properly identified
13.1 FDC plainly visible
13.1 FDC easily accessible
13.1 FDC swivels in non-binding rotation
13.1 Caps/plugs in place
13.1 Gaskets/signs in place
13.1 FDC Ball drip drain drip free
5.1 Alarm panel clear
System in Service
Comments:
5.2 Sprinkler supply gauge psi
5.2Sprinkler supply gauge ___ main drain flow psi
5.2 Sprinkler system gauge psi
5.2 Sprinkler system with main drain flow psi
Y N/A N
5.3 Interior building alarms operating
5.3 Exterior alarms operating
5.3 Inspector’s test flow psi
5.3 Time to ring alarm from
alarm check valve min sec
5.3 Time to ring alarm from
flow switch min sec
5.3 Time to ring alarm from
pressure switch min sec
Y N/A N
5.3 Gauges appear operating properly
5.1 Did alarm supervisory company receive
signal properly?
5.1 Did alarm panel reset properly?
Comments:
Y N/A N
4.1 Prior to freezing season, owner is
responsible for building to be in secure
condition and properly heated.
5.2 Visual Inspection: hanger/seismic
bracing appears attached and secure.
5.2 Visual Inspection: “exposed” piping
appears in good condition.
5.2
Piping appears free of mechanical damage.
5.2 Piping appears free of leakage.
5.2 Piping appears free of corrosion.
5.2 Piping appears properly aligned.
5.2 Piping appears free of external loads.
5.2 Sprinklers appear free of corrosion.
5.2 Sprinklers appear properly positioned.
5.2 Sprinklers appear properly spaced.
5.2
Sprinklers appear free of foreign material.
5.2 Sprinkler spray patterns appear free of
obstructions.
Comments:
Annual Testing & Maintenance Tasks that are in Addition to
Other Frequency Tasks - For Wet Sprinkler System
Y N/A N
13.3 Control valve lubricated
13.3 Control valve operated to closed
position and returned to open position
13.3 Control valve locked/tampered open
13.3 Backflow assembly control valves
operated & returned to open position
13.3 Post indicator valve operated with
_____ number of turns recorded
13.3 Post indicator valve returned to open
position
(All above listed control valves to be left 1/4 turn from wide open.)
5.3 Antifreeze solution checked to provide
adequate freeze protection:
(protection temp: _______ ° F)
Testing Frequency Items of 5 Years or Greater
14.3 Internal Inspection last date (5 years) ________
13.1 Alarm check valve
6.1 Flow tested pressure regulating control
valves***
Alarm Valve Info Y N/A N
Make
Model
Size Date
13.4 Check valve
13.4 Strainers
13.4 Filters
13.4 Trim orifices
5.3 Gauge maintenance: date last tested (5 years) _____
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test
5.3 (5 years)
High temp. date ________________
5.3 (20 years, then 10 years thereafter)
Fast response date ______________
5.3 Residential head (20 years)
5.3 (50 years, then 10 years thereafter)
Standard sprinkler date __________
Comments:
(Description of this form: These tasks are in addition to the monthly and quar-
terly tasks. Complete the monthly and quarterly reports AND this report as re-
quired for a total annual report of inspection. Visual inspection is defined as what
can be observed from the floor level by an inspector. The use of binoculars is
recommended for visual inspections in high buildings.)
JOB #
2016
06/14/2021 08:30am CDT
Holt High School
Kevin Hergenroeder, Tony Witt
Riser 3 3rd FLOOR NEW ADDITION
06/14/2021 08:30am CDT
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
75
75
65
65
40
Shotgun
2016
2006
✔
✔
21771021
600 CAMPUS DRIVE
WENTZVILLE
MO
11694 Lackland Road
St. Louis
MO
65
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

BACKFLOW PREVENTION ASSEMBLY TEST DATA AND MAINTENANCE REPORT (City of Oakland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 29 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document