Fillable Report of Inspection & Testing of (City of Oakland)

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Report of Inspection & Testing of (City of Oakland)

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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 #
2021
09/22/2021 08:00am CDT
Kuna Foodservice
Kevin Hergenroeder, Tony Witt
Pump room
09/22/2021 08:00am CDT
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50
50
45
45
42
Shotgun
2021
2007
✔
✔
22769722
704 Kuna Industrial Court
Dupo
IL
11694 Lackland Road
St. Louis
MO
45
click to sign
signature
click to edit
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signature
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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 #
2021
09/22/2021 08:00am CDT
Kuna Foodservice
Kevin Hergenroeder, Tony Witt
Riser 1
09/22/2021 08:00am CDT
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160
160
150
150
37
Shotgun
2021
2007
2007
✔
✔
22769722
704 Kuna Industrial Court
Dupo
IL
11694 Lackland Road
St. Louis
MO
150
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 #
2021
09/22/2021 08:00am CDT
Kuna Foodservice
Kevin Hergenroeder, Tony Witt
Riser 2
09/22/2021 08:00am CDT
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160
160
150
150
44
Shotgun
2021
2006
✔
✔
22769722
704 Kuna Industrial Court
Dupo
IL
11694 Lackland Road
St. Louis
MO
150
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 #
2021
09/22/2021 08:00am CDT
Kuna Foodservice
Kevin Hergenroeder, Tony Witt
Riser 3
09/22/2021 08:00am CDT
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155
155
145
145
46
Shotgun
2021
2006
✔
✔
22769722
704 Kuna Industrial Court
Dupo
IL
11694 Lackland Road
St. Louis
MO
145
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 #
2021
09/22/2021 08:00am CDT
Kuna Foodservice
Kevin Hergenroeder, Tony Witt
Main feed
09/22/2021 08:00am CDT
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✔
✔
160
160
155
155
58
Shotgun
2021
2006
✔
✔
22769722
704 Kuna Industrial Court
Dupo
IL
11694 Lackland Road
St. Louis
MO
155
1-
888-462-7642
Report of Inspection &
Testing
of Dry Pipe Fire Protection Systems
Monthly and/or Quarterly Items to be
Reviewed
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO
BE FILLED
Customer
Job #
Address
Inspector Name
Date
Inspection Frequency: Monthly Quarterly Annually Other
All “NO” answers must be fully explained.
Inspector’s Initial
Owner/Designate Rep. Initial
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
Annual Inspection of Dry Pipe
Sprinkler System
Dry Pipe Sprinkler System
Inspection
13.4 Air pressure gauge psi
13.4 Accelerate or quick opening device gauge psi
13.4 Water pressure gauge psi
13.4 Water supply gauge psi
Y N/A N
13.3 System in service on inspection
13.3 Trim valves in appropriate position
13.3 Alarm test valve closed
13.5 Intermediate chamber leak tight
13.4 Valve enclosure secured
13.4 Heater operational
13.4 Compressor operational
13.4 Oil level full
13.4 High/low pressure switches operational
13.4 Auto, air maint. devices operational
13.3 Control valve locked/tamper open
13.3 Backflow valve locked open/tamper
13.3 Valve area accessible
13.3 Control valves accessible
13.3 Main check valve holding pressure
13.7 FDC plainly visible
13.7 FDC easily accessible
13.7 FDC swivels non-binding rotation
13.7 FDC caps/plugs in place
13.7 FDC gaskets/signs in place
13.7 FDC ball drip drain drip free
5.1 Exterior alarms properly identified
5.2 Extra heads in spare head cabinet
5.2 Heads appear to be proper temperature
5.2 Head wrench for each type of head
5.2 Head in cooler appears free of ice,
corrosion
5.2 Head appears free of leakage or damage
5.2 Head appears free of paint
5.2 Head appears free of non-approved
coverings
5.3 Standard head less than 50 year
5.3 Residential head less than 20 year
5.1 Low point drum drips drained (as
frequently as needed)
4.1 All valves identified with signage
5.2 Hydraulic nameplate attached
5.1 Alarm panel clear
System in Service
Comments
Y N/A N
13.4 Quick opening devices tested during
semi-annual inspections
13.4 Quick opening device test date
________________________
13.4 Priming water at proper level
13.2 Sprinkler supply gauge with
main drain flow psi
Y N/A N
13.4 Gauges operating
13.2 Interior building alarms operate
13.2 Exterior alarms operate
5.1 Did alarm supervisory company receive
signal?
5.1 Did alarm panel reset?
Comments:
Quarterly Testing
Requirements for a Dry Pipe
Sprinkler System
Y N/A N
13.4 Inspect interior of strainers, fillers,
restricted orifices every 5th year
Date
13.4 Inspect interior of main check valve
every 5th year Date
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 Dry Pipe System
Y N/A N
13 Dry pipe valve (annually)
13.4 Dry pipe valve trip tested with control
valve partially open Date _______________
13.4 Full flow 3 year trip test Date _______________
(Exception: When protecting a cooler or heater, DO NOT introduce
moisture into system.)
Y N/A N
13.4 Information on last trip test recorded
13.3 Control valve operated to closed
position and returned to open position
13.3 Backflow assembly control valves
operated and return 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.)
14.2 Internal pipe inspection recommended
Comments:
Y N/A N
Test Frequency items of 5 Years Unless Noted
5.3 Gauge maintenance test (5 year)______
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test frequencies
5.3 (5 year) high temp. Date____________
5.3 (20 year, then 10 year thereafter)
Fast response date _________________
5.3 (50 year, then 10 year thereafter)
Standard sprinkler date _____________
F-4.1 Supplemental Information on Dry Pipe Valve and
System Condition Report (Annual)
Dry systems controls sprinklers in:
D.P.V. trip test satisfactory
Reason or failure/or partly satisfactory:
13.4 Condition: interior of body in good
condition
13.4 Condition: moving parts in good condition
13.4 Condition: seats in good condition
13.4 Condition: rubber facing in good condition
13.4 Q.O.D. operation indicate satisfactory
13.4 Q.O.D. operation indicate failed
13.4 Q.O.D. operation indicate shut off
Trip
Test
Table
If No, explain:
Dry pipe
operating
test
Dry Valve Size Year Q.O.D. Year
Make Model Serial No. Make Model Serial No.
Min Sec psi psi psi Min Sec Yes No
Without Q.O.D.
With Q.O.D.
Time water
Time to trip Water Air Trip Point reached Alarm
thru test pipe Pressure Pressure Air Pressure test outlet Operated
SYSTEM ID
Office
2021
09/22/2021 08:00am CDT
Viking
F
7
155
30
X
Kuna Foodservice
22769722
704 Kuna Industrial Court
Kevin Hergenroeder, Tony Witt
09/22/2021 08:00am CDT
30
155
155
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
145
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
6
2007
✔
✔
✔
✔
✔
✔
✔
2007
2007
2021
2020
Cooler 162
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Dupo
IL
62239
Cooler 162
2021
2021
St. Louis
MO
11694 Lackland Road
St. Louis
MO
1-
888-462-7642
Report of Inspection &
Testing
of Dry Pipe Fire Protection Systems
Monthly and/or Quarterly Items to be
Reviewed
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO
BE FILLED
Customer
Job #
Address
Inspector Name
Date
Inspection Frequency: Monthly Quarterly Annually Other
All “NO” answers must be fully explained.
Inspector’s Initial
Owner/Designate Rep. Initial
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
Annual Inspection of Dry Pipe
Sprinkler System
Dry Pipe Sprinkler System
Inspection
13.4 Air pressure gauge psi
13.4 Accelerate or quick opening device gauge psi
13.4 Water pressure gauge psi
13.4 Water supply gauge psi
Y N/A N
13.3 System in service on inspection
13.3 Trim valves in appropriate position
13.3 Alarm test valve closed
13.5 Intermediate chamber leak tight
13.4 Valve enclosure secured
13.4 Heater operational
13.4 Compressor operational
13.4 Oil level full
13.4 High/low pressure switches operational
13.4 Auto, air maint. devices operational
13.3 Control valve locked/tamper open
13.3 Backflow valve locked open/tamper
13.3 Valve area accessible
13.3 Control valves accessible
13.3 Main check valve holding pressure
13.7 FDC plainly visible
13.7 FDC easily accessible
13.7 FDC swivels non-binding rotation
13.7 FDC caps/plugs in place
13.7 FDC gaskets/signs in place
13.7 FDC ball drip drain drip free
5.1 Exterior alarms properly identified
5.2 Extra heads in spare head cabinet
5.2 Heads appear to be proper temperature
5.2 Head wrench for each type of head
5.2 Head in cooler appears free of ice,
corrosion
5.2 Head appears free of leakage or damage
5.2 Head appears free of paint
5.2 Head appears free of non-approved
coverings
5.3 Standard head less than 50 year
5.3 Residential head less than 20 year
5.1 Low point drum drips drained (as
frequently as needed)
4.1 All valves identified with signage
5.2 Hydraulic nameplate attached
5.1 Alarm panel clear
System in Service
Comments
Y N/A N
13.4 Quick opening devices tested during
semi-annual inspections
13.4 Quick opening device test date
________________________
13.4 Priming water at proper level
13.2 Sprinkler supply gauge with
main drain flow psi
Y N/A N
13.4 Gauges operating
13.2 Interior building alarms operate
13.2 Exterior alarms operate
5.1 Did alarm supervisory company receive
signal?
5.1 Did alarm panel reset?
Comments:
Quarterly Testing
Requirements for a Dry Pipe
Sprinkler System
Y N/A N
13.4 Inspect interior of strainers, fillers,
restricted orifices every 5th year
Date
13.4 Inspect interior of main check valve
every 5th year Date
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 Dry Pipe System
Y N/A N
13 Dry pipe valve (annually)
13.4 Dry pipe valve trip tested with control
valve partially open Date _______________
13.4 Full flow 3 year trip test Date _______________
(Exception: When protecting a cooler or heater, DO NOT introduce
moisture into system.)
Y N/A N
13.4 Information on last trip test recorded
13.3 Control valve operated to closed
position and returned to open position
13.3 Backflow assembly control valves
operated and return 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.)
14.2 Internal pipe inspection recommended
Comments:
Y N/A N
Test Frequency items of 5 Years Unless Noted
5.3 Gauge maintenance test (5 year)______
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test frequencies
5.3 (5 year) high temp. Date____________
5.3 (20 year, then 10 year thereafter)
Fast response date _________________
5.3 (50 year, then 10 year thereafter)
Standard sprinkler date _____________
F-4.1 Supplemental Information on Dry Pipe Valve and
System Condition Report (Annual)
Dry systems controls sprinklers in:
D.P.V. trip test satisfactory
Reason or failure/or partly satisfactory:
13.4 Condition: interior of body in good
condition
13.4 Condition: moving parts in good condition
13.4 Condition: seats in good condition
13.4 Condition: rubber facing in good condition
13.4 Q.O.D. operation indicate satisfactory
13.4 Q.O.D. operation indicate failed
13.4 Q.O.D. operation indicate shut off
Trip
Test
Table
If No, explain:
Dry pipe
operating
test
Dry Valve Size Year Q.O.D. Year
Make Model Serial No. Make Model Serial No.
Min Sec psi psi psi Min Sec Yes No
Without Q.O.D.
With Q.O.D.
Time water
Time to trip Water Air Trip Point reached Alarm
thru test pipe Pressure Pressure Air Pressure test outlet Operated
SYSTEM ID
Office
2021
09/22/2021 08:00am CDT
Viking
F 1
1
155
32
X
Kuna Foodservice
22769722
704 Kuna Industrial Court
Kevin Hergenroeder, Tony Witt
09/22/2021 08:00am CDT
✔
32
155
155
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
145
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
6
2008
✔
✔
✔
✔
✔
✔
✔
2007
2007
2021
2020
Cooler 162
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Dupo
IL
62239
Cooler 162
2021
2021
St. Louis
MO
11694 Lackland Road
St. Louis
MO
1-
888-462-7642
Report of Inspection &
Testing
of Dry Pipe Fire Protection Systems
Monthly and/or Quarterly Items to be
Reviewed
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO
BE FILLED
Customer
Job #
Address
Inspector Name
Date
Inspection Frequency: Monthly Quarterly Annually Other
All “NO” answers must be fully explained.
Inspector’s Initial
Owner/Designate Rep. Initial
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
Annual Inspection of Dry Pipe
Sprinkler System
Dry Pipe Sprinkler System
Inspection
13.4 Air pressure gauge psi
13.4 Accelerate or quick opening device gauge psi
13.4 Water pressure gauge psi
13.4 Water supply gauge psi
Y N/A N
13.3 System in service on inspection
13.3 Trim valves in appropriate position
13.3 Alarm test valve closed
13.5 Intermediate chamber leak tight
13.4 Valve enclosure secured
13.4 Heater operational
13.4 Compressor operational
13.4 Oil level full
13.4 High/low pressure switches operational
13.4 Auto, air maint. devices operational
13.3 Control valve locked/tamper open
13.3 Backflow valve locked open/tamper
13.3 Valve area accessible
13.3 Control valves accessible
13.3 Main check valve holding pressure
13.7 FDC plainly visible
13.7 FDC easily accessible
13.7 FDC swivels non-binding rotation
13.7 FDC caps/plugs in place
13.7 FDC gaskets/signs in place
13.7 FDC ball drip drain drip free
5.1 Exterior alarms properly identified
5.2 Extra heads in spare head cabinet
5.2 Heads appear to be proper temperature
5.2 Head wrench for each type of head
5.2 Head in cooler appears free of ice,
corrosion
5.2 Head appears free of leakage or damage
5.2 Head appears free of paint
5.2 Head appears free of non-approved
coverings
5.3 Standard head less than 50 year
5.3 Residential head less than 20 year
5.1 Low point drum drips drained (as
frequently as needed)
4.1 All valves identified with signage
5.2 Hydraulic nameplate attached
5.1 Alarm panel clear
System in Service
Comments
Y N/A N
13.4 Quick opening devices tested during
semi-annual inspections
13.4 Quick opening device test date
________________________
13.4 Priming water at proper level
13.2 Sprinkler supply gauge with
main drain flow psi
Y N/A N
13.4 Gauges operating
13.2 Interior building alarms operate
13.2 Exterior alarms operate
5.1 Did alarm supervisory company receive
signal?
5.1 Did alarm panel reset?
Comments:
Quarterly Testing
Requirements for a Dry Pipe
Sprinkler System
Y N/A N
13.4 Inspect interior of strainers, fillers,
restricted orifices every 5th year
Date
13.4 Inspect interior of main check valve
every 5th year Date
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 Dry Pipe System
Y N/A N
13 Dry pipe valve (annually)
13.4 Dry pipe valve trip tested with control
valve partially open Date _______________
13.4 Full flow 3 year trip test Date _______________
(Exception: When protecting a cooler or heater, DO NOT introduce
moisture into system.)
Y N/A N
13.4 Information on last trip test recorded
13.3 Control valve operated to closed
position and returned to open position
13.3 Backflow assembly control valves
operated and return 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.)
14.2 Internal pipe inspection recommended
Comments:
Y N/A N
Test Frequency items of 5 Years Unless Noted
5.3 Gauge maintenance test (5 year)______
5.3 Replaced date
5.3 Calibrated date
5.3 Sprinkler maintenance test frequencies
5.3 (5 year) high temp. Date____________
5.3 (20 year, then 10 year thereafter)
Fast response date _________________
5.3 (50 year, then 10 year thereafter)
Standard sprinkler date _____________
F-4.1 Supplemental Information on Dry Pipe Valve and
System Condition Report (Annual)
Dry systems controls sprinklers in:
D.P.V. trip test satisfactory
Reason or failure/or partly satisfactory:
13.4 Condition: interior of body in good
condition
13.4 Condition: moving parts in good condition
13.4 Condition: seats in good condition
13.4 Condition: rubber facing in good condition
13.4 Q.O.D. operation indicate satisfactory
13.4 Q.O.D. operation indicate failed
13.4 Q.O.D. operation indicate shut off
Trip
Test
Table
If No, explain:
Dry pipe
operating
test
Dry Valve Size Year Q.O.D. Year
Make Model Serial No. Make Model Serial No.
Min Sec psi psi psi Min Sec Yes No
Without Q.O.D.
With Q.O.D.
Time water
Time to trip Water Air Trip Point reached Alarm
thru test pipe Pressure Pressure Air Pressure test outlet Operated
SYSTEM ID
Office
2021
09/22/2021 08:00am CDT
Viking
F 1
1
155
40
X
Kuna Foodservice
22769722
704 Kuna Industrial Court
Kevin Hergenroeder, Tony Witt
09/22/2021 08:00am CDT
✔
40
155
155
✔
✔
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✔
✔
✔
✔
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✔
✔
✔
✔
✔
✔
✔
✔
✔
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✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
145
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
6
2014
✔
✔
✔
✔
✔
✔
✔
2007
2007
2021
2020
Loading dock
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Dupo
IL
62239
Loading dock
2021
2021
St. Louis
MO
11694 Lackland Road
St. Louis
MO
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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
1
1
1
1
IL
✔
Pump house
✔
AW KH
✔
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
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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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
3
3
1
1
IL
✔
Riser 1
✔
AW KH
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
3
3
1
1
IL
✔
Riser 2
✔
AW KH
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
3
3
1
1
IL
✔
Riser 3
✔
AW KH
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
3
3
2
1
IL
✔
Main feed
✔
AW KH
✔
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
3
3
2
4
IL
✔
Cooler 162
✔
AW KH
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
3
3
1
4
IL
✔
✔
Cooler 165
✔
AW KH
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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
09/22/2021
22769722
Kuna Foodservice
704 Kuna Industrial Court
Dupo
3
3
1
4
IL
✔
✔
Loading dock
✔
AW KH
09/22/2021
Antuan
11694 Lackland Road
St. Louis
MO
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
N/A
YES N/A
NO
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Report of Inspection & Testing of (City of Oakland)

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Completed 27 September 2021

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