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S E N T RT FIRE PROTECTION INC. 4439 Hwy.-12 SW, P.O. Box 69 Waverly,Minnesota 55390 612-658-4483 Fax#:612-658-4921 Form for Inspection, lbsting and Maintenance of Fire Sprinkler Systems sheet 1 ore Information on this form covers the minimum requirements of NFPA 25-1992 for fire sprinkler systems connected to distribution systems without supplemental tanks or fire pumps. Separate forms are available to inspect,test and maintain fire pumps and water tanks. Additional forms are also available for standpipe and hose systems,private fire service mains,water spray fixed systems and foam-water sprinkler systems. More frequen tion,testing end maintenance may be n es ary dypending on the conditions of the occupancy and the water supply. Owner:�N 0 /I'1 anlle55o if I SPC n o o L Owner's Address: Property Being Inspected: SG11010L. Property Address: 3FOO 2$ u T400G, 447�"f_ � Date of Inspection: "U All responses refer to the current inspection performed on this date. This inspection is (check one): 0 Daily 0 Weekly 0 Monthly O Quarterly 0 Semiannual X Annual ❑ Third Year ❑ Fifth Year Note: All questions are to be answered Yes.No,or Not Applicable. All"No"answers are to be explained in the comments portion of this form. Part I QWfiler'S Section 4.Monthly Inspection Items(Continued) A.Is the buildmg occupied?; Yes O No O N/A F.Sprinkler Pressure Regulating Control Valves: B. Hasthe classification and hazar of tents remained 1.In open position? O Yes O NodN/A the same since the last inspection? Yes O:Nn O N/A C. Are all'ftre protection systems in service?` rs O No;O N/A 2.Not leaking. O Yes ❑No,�N/A D. Has the;system remained m-service without modifieatton since the 3.Maintaining downstream pressure per design criteria. last inspection? es O No O N/A O Yes 0 No QN/A E. 4.In good condition with handwheels not broken?❑Yes ONoI/A Was the system free o ' [mations devices arms since the r#st inspection? Yes O No 0 N/A G.Fire Department Connections: 1.Visible and accessible? Wfes 0 No O N/A at2.Couplings and swivels not damaged and rotate smoothly??Owner or Representative Tint name Signature and DeYes o No O N/A II• Inspectors Section f A.Inspections 3.Plugs or caps in place and undamaged? Yes 0 No ❑N/A 1.Daily,or weekly it low temperature alarms are installed 4.Gaskets in place and in good condition? Q'Ifes 0 No ❑N/A Enclosures around dry-pipe,preaction or deluge valves maintaining 5.Identification sign(s)in place? Ad*fes 0 No 0 N/A a minimum of 40°F? ❑Yes O No X N/A 6.Check valve is not leaking? gYes 0 No ❑N/A 2.Weekly Inspection Items 7.Automatic drain valve in place and operating properly? A.Pmaction and Deluge Valves: Uttes 0 No 0 N/A 1.Free from physical damage? 0 Yes 0 No qxN/A (Note: If plugs or caps are not in place,inspect the interior for 2.Trim valves in appropriate(open orclosed)position and no obstructions and verify that the valve clapper is operational over its leakage frgm valve seat? O Yes 0 No WN/A full range.) 3.Electrics components in service? 0 Yes 0 No Rf N/A S.Quarterly Inspection Item B.Dry-Pipe Valves: Hydraulic nameplate,if provided,securely attached to riser and 1.Free from physical damage? ❑Yes ONO id N/A legible? Yes 0 No 0 N/A 2.Trim valves in appropriate(open or closed)position? 6.Annual Inspection Items O Yes 0 No 0 N/A A.Visible sprinklers: 3.No leakage from intermediate chamber? 0 Yes O No RrN/A 1.Free of corrosion? JOYes O No 0 N/A C.Relief port on reduced pressure backflow prevention assemblies 2.Free of obstructions to spray patterns? James ❑No O N/A free of continuous dischare? O Yes O No 0 N/A 3.Free of foreign materials including paint? O'Yes ❑No 0 N/A 3.Weekly inspection items which can be performed monthly if the 4.Free of physical damage? eYes 0 No 0 N/A Items are electrically supervised or secured with locks B.Visible pipe: A.Gauges on dry,preaction and deluge systems in good condition and 1.In good condition? WYes O No O N/A showing normal air and water pressure? O Yes O No)dN/A 2.Free of mechanical damage and not leaking?;'Yes O No 0 N/A B.Control valves: 3.No external corrosion? 1�'Yes O No 0 N/A 1.In normal(open or closed ition? RrYes 0 No 0 N/A 4.Properly aligned? OYes O No 0 N/A 2.Sealed,locked pervis 0Yes ONO 0 N/A 5.No external loads? dYes 0 No O N/A 3.Accessible? gryCS 0 No 0 N/A C.Visible pipe hangers and seismic braces not damaged or loose? C.Isolation valves on backflow prevention assemblies in open FdrYes 0 No 0 N/A position? O Yes ❑No U(N/A D.Adequate heat available to areas where wet sprinkler piping is 4.Monthly Inspection Items located?(Must be done before cold weather.)XYes ❑No O N/A A.Proper number and type of spare sprinklers? Yes 0 No 0 N/A . 7.Annual,or every fifth year for valves which can be reset without B.Sprinkler wrench with spare sprinklers? Q6cs ❑No O N/A opening: C.Gauges on wet-pipe system in good condition and showing normal Interior of dry-pipe,preaction and deluge valves passed internal water supply pressure? Yes ONO O N/A inspection? 0 Yes 0 No JdN/A D.Alarm devices free from physical damage and all electrical 8.Fifth Year Inspection Items connections secure? XYes O No 0 N/A A.Alarm valves and their associated strainers,filters and restriction E.Alarm Valves: orifices passed internal inspection? 0 Yes O No VN/A 1.Gauges indicating normal supply water pressure?OYes O No N/A B.Check valves internally inspected and all parts operate properly, 2.Free from physical damage? 0 Yes ❑No UN/A move freely and are in good condition? O Yes 0 No Jff N/A 3.Valves in appropriate(open or closed)position?OYes 0 No ;rN/A C.Strainers,filters,restricted orifices and diaphragm chambers on 4.No leakage from retarding chamber or alarm drains? dry-pipe, preaction and deluge valves passed internal inspecti n? 0 Yes 0 No 0 N/A O Yes O No;d N/A