Fillable Record of inspection - special hazards system CUSTOMER (City of Oakland)

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Record of inspection - special hazards system CUSTOMER (City of Oakland)

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  • 73 check-boxes
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File type: PDF

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Record of inspection - special hazards system
DATE:
ANNUAL
WORK ORDER #:
SEMI-ANNUAL
CUSTOMER
ADDRESS
MONTHLY
OTHER
CONTACT
EMAIL
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.
HAZARD DESCRIPTION
1. SYSTEM LOCATION?
2. HAZARD TYPE?
SINGLE HAZARD MULTIPLE HAZARD
SINGLE ROOM / AREA MULTIPLE ROOM / AREA
3. BUILDING ALARM DETECTORS PRESENT IN HAZARD?
YES NO
4. FIRE SPRINKLER PRESENT IN HAZARD?
YES NO
5. AGENT SUPPLY TYPE?
MAIN SUPPLY ONLY MAIN / RESERVE
ON SITE READY
RESERVE
6. SUB FLOOR PRESENT?
YES NO N/A
7. DEDICATED HVAC?
YES NO N/A
8. DAMPERS INSTALLED?
YES NO N/A
9. CIELING TYPE?
HARD DECK DROP CEILING N/A
OPEN PLENUM OTHER
10. DESCRIPTION OF HAZARD UPON ARRIVAL:
11. TYPE OF SYSTEM?
CLEAN AGENT HI PRESSURE CO2 LOW PRESSURE CO2
DRY CHEMICAL OTHER:
12. MANUFACTURER OF SYSTEM?
ANSUL KIDDE PYROCHEM
FIKE CHEMETRON OTHER:
13. TYPE OF SUPPRESSION AGENT?
FM-200
(HFC-227ea)
NOVEC 1230
(FK-5-1-12)
INERGEN
(IG-541)
ECARO-25
(HFC-125)
CO2
HALON 1301
(HFC-1301)
OTHER
11/5/21
23324970
Republic Services
6025 Byassee Drive
Hazelwood
✔
✔
Kevin Hergenroeder, Tony Witt
11694 Lackland Road
MO
MO
✔
✔
✔
Amerex
Abc
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signature
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14. CYLINDERS
SERIAL NUMBER
CYLINDER
CAPACITY
AGENT (FILL)
WEIGHT
FULL (GROSS)
WEIGHT
EMPTY (TARE)
WEIGHT
PRESSURE
READING
LAST HYDRO DATE
CYLINDER 1
CYLINDER 2
CYLINDER 3
CYLINDER 4
TOTAL # OF CYLINDERS? *CYLINDER SHEET ATTACHED FOR ADDITIONAL CYLINDERS?
15. PIPING NETWORKS
QUANTITY?
PROPERLY BRACED?
YES NO
CHECKED FOR OBSTRUCTIONS?
YES NO
FLEXIBLE DISCHARGE HOSES?
# LAST HYDRO?
QUANTITY OF DISCHARGE NOZZLES?
180 DEG 360 DEG
CO2 OTHER:
16. SYSTEM CONTROL PANEL
TYPE?
CONVENTIONAL ADDRESSABLE
LOCATION?
MANFUCTURER?
MODEL?
CIRCUIT STYLE?
CLASS A CLASS B
OTHER:
PRIMARY VOLTAGE? SECONDARY VOLTAGE?
DISCONNECT OR BREAKER LOCATION AND LABEL?
17. BATTERIES
NOT INSTALLED LOCATION AMP RATING DATE
VOLTAGE
READING
LOAD TEST RESULT
BATTERY 1
BATTERY 2
BATTERY 3
BATTERY 4
18. INPUT DEVICES
# INSTALLED # TESTED
VISUAL
INSPECTION #
PASSED
FUNCTIONAL
TESTING # PASSED
COMMENTS
SMOKE DETECTORS
HEAT DETECTORS
YES
30182
50
350
2019
46524
50
350
2019
Cab
Amerex
Circuit monitor
2
✔
✔
FLAME DETECTORS
GAS DETECTORS
ELECTRIC MANUAL RELEASE
MECHANICAL MANUAL RELEASE
(LOCAL ACTUATOR)
LOCKOUT/ BYPASS SWITCH
ABORT SWITCH
DISCHARGE PRESSURE SWITCH
CYLINDER LOW PRESSURE SWITCH
ACTUATOR PLACEMENT SWITCH
PULL STATION
(ALARM OUTPUT ONLY)
19. OUTPUT DEVICES
# INSTALLED # TESTED
VISUAL
INSPECTION #
PASSED
FUNCTIONAL
TESTING # PASSED
COMMENTS
HORN STROBE COMBINATION
STROBE
HORN
ALARM BELL
PRESSURE OPERATED SIREN
ELECTRIC ACTUATOR
NON-RESETTABLE?
ELECTRIC SOLENOID
20. RELAYS
# INSTALLED # TESTED LOCATION
FUNCTIONAL
TESTING # PASSED
COMMENTS
TROUBLE RELAY
SUPERVISORY RELAY
GENERAL ALARM RELAY
PREDISCHARGE RELAY
DISCHARGE RELAY
OTHER
LIST ITEMS SHUTDOWN OR CONTROLLED BY
RELAYS:
21. GENERAL COMMENTS:
22. RECOMMENDATIONS:
23. LIST OF CHANGES MADE AND/OR EQUIPMENT REPLACED OR ADDED
24. SYSTEM STATUS UPON DEPARTURE?
OPERATIONAL INOPERABLE
OPERATIONAL WITH DEFICIENCIES
SYTTEM ARMED?
YES NO
SYSTEM TAG UPDATED?
YES NO
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.
✔
✔
✔
11/05/2021
Ray Riddle
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signature
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Record of inspection - special hazards system CUSTOMER (City of Oakland)

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Completed 22 November 2021

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