Fillable Record of Obstruction Investigation CUSTOMER ADDRESS CONTACT (City of Oakland)

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Record of Obstruction Investigation CUSTOMER ADDRESS CONTACT (City of Oakland)

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Record of Obstruction Investigation
DATE:
SYSTEM(S) INVOLVED
WORK ORDER #:
WET
CUSTOMER
DRY
ADDRESS
PRE-ACTION
DELUGE
CONTACT
OTHER
EMAIL
DATE OF PREVIOUS INTERNAL PIPE INSPECTION:
PHONE
inspector's name
LICENSE
inspector's signature
I state the information on this form is correct at the time and place
of my inspection,and that all equipment tested at this time was left
in operational condition upon completion of this inspection except
as noted.
An examination of representative section of this sprinkler system has been made to determine internal conditions
INITIAL EXAMINATION DATA:
1. Number of branch
lines examined:
2. Number of cross
mains examined:
3. Number of mains
examined:
4. Number of
gauges
replaced:
5. Alarm valve
information:
6. Other points
examined (describe):
RESULTS OF INITIAL EXAMINATION:
The interior of the sprinkler piping appears in satisfactory condition
The sprinkler systems are in need of internal cleaning. Some of the pipes
were found to be partially full of foreign materials.
(specify nature of internal stoppage)
EXAMINATION SUBSEQUENT TO CLEANING SYSTEM:
7. Number of branch
lines examined:
8. Number of cross
mains examined:
9. Cleaning method
used?
10. Other points examined (describe):
RESULTS OF EXAMINATION SUBSEQUENT TO CLEANING SYSTEM:
The interior of the sprinkler piping appears in satisfactory condition
If interior of piping other than
satisfactory, describe:
Owner / designated rep name
DATE
Owner / deisgnated rep signature
I state that the information on this form has been explained at my
request and a copy provided to me regarding this inspection,and
that all equipment tested at this time was left in operational
condition upon completion of this inspection except as noted.
page 1 of 2
888-462-7642
05/06/2021
21398557
CF OLD NAVY #4506
16 THF BLVD, CHESTERFIELD COMMONS
CHESTERFIELD
5
4
2
MO
✔
✔
A Witt
11694 Lackland Road
St. Louis
MO
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Record of Obstruction Investigation and Internal Condition of Fire Protection System Piping
Annual Ice Obstruction on Internal
Investigation applicable? 5 Year Investigation and Prevention
1. System in service before
conducting investigation?
9. System in service before conducting
investigation?
2. Pertinent parties notified before
conducting investigation?
10. Pertinent parties notified before
conducting investigation?
3. System impairment program
implemented before conducting
investigation?
11. Adequate drainage ensured before
draining system?
4. Piping internally inspected for ice
obstruction at entrance points to
refrigerated areas?
12. System impairment program
implemented before conducting
investigation?
5. Alternative non-destructive
examination method utilized?
13. Flushing connection of one main
and sprinkler of one branch line
removed?
6. Evidence of ice obstruction found?
14. Alternative non-destructive
examination method utilized?
7. Additional piping exmained to
ensure no ice blockage exists if "NO"
on item #6 above?
15. Foreign material indicated by
non-destructive examination method?
8. Pertinent parties notified of
investigation conclusion?
16. Interior of main, branch line, and
sprinkler outlet checked for presence
of tubercules or slime?
COMMENTS:
17. Any tubercles or slime observed?
18. Complete flushing program
implemented where observed material
sufficient to obstruct sprinklers?
Description:
Date:
Testing for Microbiologically influenced corrosion (MIC)
19. Tubercules or slime (if present)
tested for indications of MIC?
Description:
Date:
20. Material test results do not indicate
presence of MIC?
Desciption:
Date:
21. MIC abatement / monitoring
program implemented, if "NO" on item
#20 above?
Description:
Date:
22. Pertinent parties notified of
investigation conclusion?
23. ALARM PANEL CLEAR?
24. SYSTEM RETURNED TO
SERVICE?
page 2 of 2
YES
NO
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YES N/A
NO
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Record of Obstruction Investigation CUSTOMER ADDRESS CONTACT (City of Oakland)

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Completed 28 June 2021

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