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Testing of Report of Inspection & (City of Oakland)

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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
05/19/2021 07:00am CDT
YMCA
Kevin Hergenroeder, Tony Witt
05/19/2021 07:00am CDT
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55
55
50
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Shotgun
2021
1992
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21589721
1635 West 1st Street
Granite City
IL
11694 Lackland Road
St. Louis
MO
50
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signature
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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
05/25/2021
21589721
YMCA
1635 West 1st Street
Granite City
3
3
1
1
IL
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A Witt
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05/25/2021
Darrin
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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Completed 9 September 2021

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