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FIRE ALARM TEST/INSTALLATION <br /> Simplex Simplex Time Recorder ACKNOWLEDGEMENT <br /> Gardner,Massachusetts 0144144 1 U.S.A. <br /> BRANCH SERVICE AT CUSTOMER NUMBER J� <br /> �ARRW� ATE ( TR COMP.DATE BILLABLE I NON-BILL <br /> NSP.DATE PROJECT NO. IP.CODE SERV.CODE INSTAL. <br /> ❑MTHLY ❑SEMI-AN <br /> ❑ORTLY ❑ANNUAL <br /> ADDRESS(OR ATTR OF) CUSTOMER PURCHASE ORDER AND/OR CUSTOMER CONTACT NAME(PRINT) FINAL <br /> all I <br /> ADDRESS iw <br /> LABOR HRS TRAVEL HRS MILES TR TERR. M.A. <br /> CwfSTATE ZIP LABOR HRSI TRAVEL HRS TM.3 LABOR HRS TRAVEL HRS <br /> :;ONTROL <br /> MA A TUREF{"- MODEL NO.�!�/ SE IO. WI NG DUAG.NO. SEQUENCE NO. <br /> (� THRU <br /> TYPE OF SIGNALING POWER CIR.BRKR.LOCATION NO. LOCKED CIR.BRKR DEDICATED CIR. <br /> ❑GENERAL ALARM ❑SELECTIVE SIGNALS ❑CODED ❑ PRE-SIGNAL SOURCE ❑Y ❑N ❑Y ❑ N <br /> VOLTAGE WITH CHARGER El <br /> [I�� <br /> ❑NORM TROUBLE RESPONSE TO: ZONE TROUBLE SIGNAL TROUBLE AC/OP POWER LOSS EARTH GROUND <br /> BATTERIES VOLT WITHOUT CHARGER [IN/A : CONDITIONS <br /> ❑ El NORM El NOTE# NOJJM ❑ NOTE# ❑Now 11 NOTE# 1-1 NORM ❑ NOTE# <br /> CUSTOMER OPERATING INSTRUCTIONS PROVIDED TO: STR TR 1 SIGNATURE <br /> GUSTO R SI 'R FIRE ALARM LICEPtSE NO.-STATE CERTIFICATIO NO. <br /> SEE NOTAT O. THE SIM LEX-SUPPLIED EQUIPMENT FOR THIS SYSTEM WAS TESTED AND <br /> FOUND OPERATIONAL. SIGNALS WERE NOT SOUNDED PER CUSTOMER REQUEST <br /> THE WARRANTY BEGINS ON MONTH DAv YR, ❑Y ❑N <br /> 4UXILIARY FUNCTIONS <br /> MFGR. SERIAL DOOR DOOR RELEASE DEVICES,INCLUDING CLOSERS AND LATCHES <br /> ANNUNCIATOR HOLDERS <br /> ❑NORM ❑ QTY. ❑ NOTE# N/A <br /> MODEL WIRING DIAGRAM ELEVATOR RECALL TO PRIMARY FLOOR <br /> FIRE RECALL ❑NORM ❑ NOTE# N/A <br /> [I NCAND. El GRAPHIC [I CRT VOLTAGE NO.OF ZONES UNUSED PTS. RECALL TO ALTERNATE FLOOR <br /> TYPE ELEVATORS RESTART <br /> LED DROP FROM FIRE VC. <br /> ElLEDEl NORM E] NOTE# /A AUTOMATICALLY ❑Y ❑N <br /> ADDITIONAL NOTES: AIR HANDLER SHUTDOWN <br /> AUX El LAMP TEST El REMOTE RESET HVAC AIRHANDLER(S) <br /> FUNCTIONS ❑DRILL SW ❑REMOTE A K SHUTDOWN RESTART FROM <br /> ❑ NORM ❑NOTE# ❑ QTY. SHUTDOWN AUTOMATICALLY ❑v ❑N <br /> UNIQUESPECIAL LIST ANY • <br /> CONSIDERATIONS TO BE AWARE OF •' <br /> CITY CRY RESPONSE TO ALARM OFFICIAL CONTACTED 1 <br /> CONNECTION OR ❑NORM ❑NOTE# Yt r <br /> CENTRAL MONITORING CITY RESPONSE TO TROUBLE TIME OF DAY X <br /> STATION ❑NORM ❑NOTE# OUT OF SERVICE IN SERVICE <br /> LOCAL FIRE DEPT./CENTRAL STATION FD.BUS.PHONE NO./CENTRAL STATION 3 <br /> MPX/TPR CHECK LIST PERIPHERAL/PARTS USED THE NUMBER OF <br /> MODEL No. THE FOLLOWING <br /> ! • <br /> TRANSPONDERS MODEL/ID/PART NO. CHARGE ITEM TOTAL NO No. ✓okay <br /> FAILED THE TEST (X) CODE QTY. UNIT PRICE OF DEVICES Tested XSee below <br /> NO.OF XPNDRS TESTED LOCATION NOTE# i 1 <br /> 1 STATIONS `""r <br /> POWER SUPPLY VOLTAGE NOTE# LOCATION NOTE# HEAT UETECTORS — - <br /> ❑NORM 2 SMOKE DETECTORS <br /> CHARGER VOLTAGE NOTE#LOCATION NOTE# 3 d <br /> ANNUNCIATORS <br /> ❑NORM <br /> GROUND FAULT NOTE 4 LOCATION NOTE# DUCT DETECTOR <br /> ❑Y ❑N 4 HORNS G-- <br /> BATTERIES VOLTAGE NOTE# LOCATION NOTE# 5 BELLS <br /> ❑NORM <br /> CHIMES <br /> POINTS TESTED NOTE# LOCATION NOTE# <br /> ❑NORM 6 SPRINKLER SYST <br /> OTHER NOTE# LOCATION NOTE* 7 NURSE CALL <br /> PRINTERS NOTE# CRT'S NOTE# OTHER NOTE# TYP —SL <br /> Ely [IN Ely ❑N $ L� <br /> NOTATIONS • DA • ENCOUNTERED DURING TEST <br /> M552-1FV 3-91 IF DETAILED TESTING IS REQUIRED-USE CONTINUATION SHEET ADV-0352 9-88 <br /> AUTHORITY HAVING JURISDICTION -� <br />