BACKFLOW PREVENTION ASSEMBLY TEST REPORT
NAME OF PREMISE Commercial Residential
SERVICE ADDRESS
CUSTOMER PRINTED NAME PHONE FAX
LOCATION OF ASSEMBLY
TYPE OF HAZARD ISOLATED DCVA RPBA OTHER
NEW INSTALLATION EXISTING REPLACEMENT LINE PRESSURE: PSI
MAKE OF ASSEMBLY MODEL SERIAL # SIZE ”
AIR GAP INSPECTION: Required minimum air gap separation provided? Yes No PROPER INSTALATION? YES NO
INITIAL TEST
PASSED
FAILED
DCVA / RPBACHECK VALVE #1
DCVA / RPBACHECK VALVE #2
RPBA PVBA / SVBA
LEAKED CLOSED TIGHT
PSID
LEAKED CLOSED TIGHT
PSID
OPENED AT PSID AIR INLETOPENED AT PSID
#1 CHECK PSID
AIRGAP OK? DID NOT OPEN
NEW PARTSAND
REPAIRS
CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVEHELD AT PSID
LEAKED
CLEANED
REPAIRED
TEST AFTERREPAIRS
PASSED FAILED
CLOSED TIGHT CLOSED TIGHT OPENED AT PSID AIR INLET PSID
PSID PSID #1 CHECK PSID CHECK VALVE PSID
Detector Meter Reading:
LINE PRESSURE PSI CONFINED SPACE? YES NO
REMARKS:
TESTER’S SIGNATURE: CERT #: DATE:
TESTER’S NAME PRINTED: TESTERS PHONE #
REPAIRED BY: LIC. #: DATE:
FINAL TEST BY: CERT #: DATE:
CUSTOMER’S SIGNATURE: DATE:
CALIBRATION DATE: GAUGE #: SERVICE RESTORED? YES NO
BACKFLOW PREVENTION ASSEMBLY TEST REPORT
NAME OF PREMISE Commercial Residential
SERVICE ADDRESS
CUSTOMER PRINTED NAME PHONE FAX
LOCATION OF ASSEMBLY
TYPE OF HAZARD ISOLATED DCVA RPBA OTHER
NEW INSTALLATION EXISTING REPLACEMENT LINE PRESSURE: PSI
MAKE OF ASSEMBLY MODEL SERIAL # SIZE ”
AIR GAP INSPECTION: Required minimum air gap separation provided? Yes No PROPER INSTALATION? YES NO
INITIAL TEST
PASSED
FAILED
DCVA / RPBACHECK VALVE #1
DCVA / RPBACHECK VALVE #2
RPBA PVBA / SVBA
LEAKED CLOSED TIGHT
PSID
LEAKED CLOSED TIGHT
PSID
OPENED AT PSID AIR INLETOPENED AT PSID
#1 CHECK PSID
AIRGAP OK? DID NOT OPEN
NEW PARTSAND
REPAIRS
CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVEHELD AT PSID
LEAKED
CLEANED
REPAIRED
TEST AFTERREPAIRS
PASSED FAILED
CLOSED TIGHT CLOSED TIGHT OPENED AT PSID AIR INLET PSID
PSID PSID #1 CHECK PSID CHECK VALVE PSID
Detector Meter Reading:
LINE PRESSURE PSI CONFINED SPACE? YES NO
REMARKS:
TESTER’S SIGNATURE: CERT #: DATE:
TESTER’S NAME PRINTED: TESTERS PHONE #
REPAIRED BY: LIC. #: DATE:
FINAL TEST BY: CERT #: DATE:
CUSTOMER’S SIGNATURE: DATE:
CALIBRATION DATE: GAUGE #: SERVICE RESTORED? YES NO
FIRE ALARM SYSTEM (One System per Report)
CTF 8005 System Status Given
CONFIDENCE TEST REPAIRS RED YELLOW GREEN
Frequency Annual: Semi-Annual: Quarterly:Date of Inspection:
Occupancy Information Occupancy Name: Occupancy Address:
Building Owner: Phone Number: Owner Address:
Contact Person: Phone Number:
System Information (where applicable) Central Station Monitoring Yes No Monitoring Company Name:
Control Panel Manufacturer: Model Number:
Location of System:
Testing Agency Information Fire Protection License: Washington State Contractor License: NICET Number:
Testing Agency Name:
Address:
Phone:
E-mail:
Problems Found: (Explain any “no” responses and use additional paper if needed)
Corrections Made:
Date Corrected: _________ Corrected by: (Print) (Sign) This report certifies this fire and life safety system has been properly inspected for reliability to cover the items listed in the report and is consistent with NFPA 72 Standard. All discrepancies are noted and have been reported to the building owner or responsible person for corrective action.
TECH NAME: (Print) (Sign) Date:
Building Representative: (Print) (Sign) Date:
AAA FIRE & SAFETY INC. 3013 3rd Ave N., Seattle WA 98109
(206) 284-1721
AAA FIRE & SAFETY, INC.3013 3RD AVE NORTHSEATTLE, WA 98109
"THE NORTHWESTS MOST TRUSTED NAME IN FIRE PROTECTION"
Tacoma Fire DepartmentConfidence Test Officer 253.591.5740
FAX Number 253.594.7943 Red Tag FAXLINE Number 253.591.5034
3471 S. 35th St. Tacoma, WA 98409
The items on the checklists below shall be inspected and tested. This list does not constitute all of the required inspecting and testing of the fire and life safety system. Refer to the NFPA 72 Standard for inspecting and testing requirements.
ALARM SYSTEM FUNCTIONALITY YES NO Trouble signal with AC power off? System operates properly on battery backup? Battery voltage (no load) _________ volts Battery voltage (full load) (signals operating) _________ volts (signals operating) Charge circuit voltage _________ volts System operates properly on standby power? All signals operate on AC power Number of initiating circuits: Number of signal circuits: Does the system meet audibility standards? All circuits checked for electrical supervision? All auxiliary equipment operates (Elevators, fans, dampers)? N/A Ventilation controls operate? N/A Key to panel available? Operating instructions at panel? The elevator call down functions properly? N/A Test record posted at panel? General alarm automatic time delay __________ (minutes) N/A Other devices (specify) __________ Was a full walk through done?
Test Results Acceptable System Devices Total Number of Units inBuilding
Total Number Units Tested N/A YES NO
Bells, Horns & Chimes Voice Speakers (voice clarity) Operations Test
1. Smoke Detector2. Duct Detector
Sensitivity Test 1. Smoke Detector2. Duct Detector
Heat Detectors Sprinkler Flow Switches Sprinkler Supervisory Switches Visual Alarm Devices Manual Pull Stations Automatic Door Unlocks Automatic Door Release
Test Acceptable Communication Equipment Total Number of Units in Building
Total Number Units Tested N/A YES NO
Phone Sets Phone Jacks Call-in Signal
STAIRWAY DOOR LOCKS
SYSTEM FUNCTIONALITY YES NO
Number of stories? ________
Do all locking devices release upon activation of the fire alarm system?
Do all locking devices release upon power failure?
Does the door to roof unlock?
Do doors unlock but not unlatch?
Is there an access key at the control panel for doors that fail to unlock?
Test Acceptable System Devices Total Number of Units in Building
Total Number Units Tested N/A YES NO
Electric Strike
Electric Bolt
Other locking devices
Building is not equipped with Stairway Door Lock system.
WET – AUTOMATIC SPRINKLERS(One System per Report)
CTF 8002 System Status Given
CONFIDENCE TEST REPAIRS RED YELLOW GREEN Frequency 5 Year: Annual: Semi-Annual: Quarterly:
Date of Inspection: Occupancy Information
Occupancy Name: Occupancy Address:
Building Owner: Phone Number: Owner Address:
Contact Person: Phone Number:
System Information (where applicable) Central Station Monitoring Yes No Monitoring Company Name:
Control Panel Manufacturer: Model Number:
Location of Riser:
Max Height # of Heads System # TFD System #
Testing Agency Information Fire Protection License: Washington State Contractor License: NICET NUMBER:
Testing Agency Name:
Address:
Phone:
E-mail:
Problems Found (Explain any “no” responses and use additional paper if needed):
Corrections Made:
Date Corrected: ________ Corrected by: (Print) (Sign) This report certifies this fire and life safety system has been properly inspected for reliability to cover the items listed in the report and is consistent with NFPA 25 Standard. All discrepancies are noted and have been reported to the building owner or responsible person for corrective action.
TECH NAME: (Print) (Sign) Date:
Building Representative: (Print) (Sign) Date:
(2
Washington State Inspector's License:
AAA FIRE & SAFETY, INC.3013 3RD AVE NORTHSEATTLE, WA 98109
"THE NORTHWESTS MOST TRUSTED NAME IN FIRE PROTECTION"
Tacoma Fire DepartmentConfidence Test Officer 253.591.5740
FAX Number 253.594.7943 Red Tag FAXLINE Number 253.591.5034
3471 S. 35th St. Tacoma, WA 98409
The items on the checklists below shall be inspected and tested. This list does not constitute all of the required inspecting and testing of the fire and life safety system. Refer to the NFPA 25 Standard Inspection, Testing and Maintenance of Water Based Fire Protection Systems requirements.
SYSTEM FUNCTIONALITY
Was a full walk through performed? Yes No
Is building fully sprinkled? Yes No
Is there a calculation plate? Yes No
What is the design density? (gallons per sq ft.)_______________
Main drain flow test conducted? Yes No
Static pressure: __________ psi Residual Pressure: __________ psi Test pipe size? ___________
Flow switches, supervisory switches and alarm bells tested satisfactorily N/A Yes No
Water motor gong operates properly? N/A Yes No
System is free of any recalled heads? Yes No
Pressure regulating valves tested satisfactorily? N/A Yes No
Valves are locked or supervised? Yes No
Signs are provided on control valves? Yes No
Sprinkler heads are less than: 1. 50 years for Standard Response Yes No 2. 20 years for Fast Response N/A Yes No 3. 10 years for Dry Type N/A Yes No 4. 5 years for solder type with extra high temperature rating N/A Yes No 5. A sample has been successfully tested within the last 10 years Yes No
Sprinkler heads free of corrosion, paint, obstructions and/or physical damage? Yes No
Proper number of spare sprinkler heads available? Yes No
Sprinkler wrench available for each type of sprinkler? Yes No
Minimum of 18” clearance between top of storage and sprinkler deflector? Yes No
Did antifreeze systems test satisfactorily? N/A Yes No
Is building adequately heated? Yes No
System left in service with an inspection tag posted main valve? Yes No
System gauges replaced or calibrated every 5 years? Yes No
Fire Department Connection in satisfactory condition, couplings free, caps in place, check valves tight? Yes No
Was the Fire Department Connection (FDC) internal inspection completed? (req every 5 years) Date: Yes No
Was debris found in the Fire Department Connection (FDC)? Yes No When was an internal pipe inspection performed? (req every 5 years) Date: ______________
CPVC N/A
Yes No
Testing agency has informed owner of legal obligation to perform inspections, testing and maintenance in accordance with NFPA 25.
Yes No