Fire Alarm Service & Inspection Form
Fire Alarm Service & Inspection Form
Monthly Quarterly Semi Annual Annual
County Fire Protection, Inc.
2937 Switzer Ave. Columbus, Ohio 43219 Phone 614-252-6630 Fax 614-252-6640 Customer Kroger 818 Bethel Rd Address 2090 Bethel Road City/State Columbus Contact Phone (614) 326-5645
4620 Crystal Parkway Kent, Ohio 44240 Phone 330-673-3600 Fax 330-673-1600
OH
ManufacturerSilent Knight Model # SK-5208 No. of circuits Style Revision# Install date Date last serviced Monitored Y N Company Acct # Phone# Digital City Box Reverse Polarity Radio Other System Controls Control panel Yes No N/A Interface equipment Yes No N/A Lamps/LEDs Yes No N/A Fuses Yes No N/A Primary power supply Yes No N/A Trouble signals Yes No N/A Disconnect switch Yes No N/A Ground fault Yes No N/A Primary voltage Amps Disconnect location Locked Battery voltage Amp hrs Battery type Sealed Lead Dry Cell Ni Cad Other Date Battery condition Good Fair Poor Charger operable Yes No N/A Automatic switch over Yes No N/A Engine driven generator Yes No N/A Fuel storage location Alarm Initiating Devices Manual stations Ion smoke detectors Photo smoke detectors Duct detectors Heat detectors Waterflow switches Supervisory switches Kitchen system Suppression system Other
Functional Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Alarm Indicating Devices Bells Horns Horn strobes Strobes Sirens Speakers Speaker strobes Chimes Lights Deficiencies found
Functional Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Date 01/18/2016 08:00am EST, 01/ Man Hrs.
812 Warehouse Road, Unit D Toledo, Ohio 43615 Phone 419-535-0955
Emergency Communications Equipment Functional Phone sets Yes No Phone jacks Yes No Off hook indicator Yes No Amplifiers Yes No Tone generator Yes No Call in signals Yes No System performance Yes No Remote annunciators Yes No Supervising Station Monitoring Alarm signal Yes Alarm restoration Yes Trouble signals Yes Trouble restoral Yes Supervisory signals Yes Supervisory restoral Yes
No No No No No No
Notification of Testing Monitoring entity Building occupants Building management Other
Yes Yes Yes Yes
No No No No
Impairments reported AHJ Building management
Yes Yes
No No
System returned to normal
Yes
No
Count N/A N/A N/A N/A N/A N/A N/A N/A Time
Date Time
Comments
Count N/A N/A N/A N/A N/A N/A N/A N/A N/A * System Tested in Accordance with NFPA Standards Count N/A N/A N/A N/A N/A N/A N/A N/A N/A
Technician Charles Shoemaker, Bill Henderson Signature State License Number Name of owners rep Signature Other representative Signature
4620 Crystal Parkway Kent, Ohio 44240 phone 330-673-3600 fax 330-673-1600
812 Warehouse Rd., Unit D Toledo, Ohio 43615 phone 419-535-0955 fax 419-380-8650
2937 Switzer Ave. Columbus, Ohio 43219 phone 614-252-6630 fax 614-252-6640
35169 E Michigan Ave #164 Wayne, MI 48184 toll free 1-888-528-0928
WATER BASED FIRE PROTECTION INSPECTION & TEST REPORT
www.county-fire.com
01/18/2016 08:00am EST, 01/28/2016 08:00am EST Kroger 818 Bethel Rd SITE CONTACT (614) 326-5645 PHONE ADDRESS 2090 Bethel Road Columbus OH CITY STATE DATE
This inspection is:
Annual
Semi-Annual
Quarterly
Monthly
Weekly
Other
This section is to be answered by the Owner or Representative
1 - OWNERS SECTION
YES
N/A
NO
YES
N/A
NO
YES
N/A
NO
YES
N/A
NO
A. Is the building occupied? B. Has the occupancy classification and hazard of contents remained the same since the last inspection?
(If NO, an Engineering Survey is required)
C. Are all the fire protection systems in service? D. Has the system remained in service without modification since the last inspection? E. Was the system free of actuation of devices or alarms since the last inspection?
(Water Flow Alarms and Supervisory Alarms)
F. Are all Wet Sprinkler System piping and Wet portions of Dry Systems protected from temperatures below 40° F?
2 - GENERAL A. Have the sprinkler systems been extended to all visible areas of the building?
(If NO, an Engineering Survey is required)
B. Does there appear to be proper clearance between the top of all storage and the sprinkler deflector? C. Are the hydraulic nameplate(s) securely attached to the riser and legible?
(Answer N/A if system is Pipe Scheduled)
D. Is there a spare head box with the proper number and type of spare sprinklers and wrenches? E. Are Fire Dept. Connections in satisfactory condition, couplings free, caps / plugs in place, ball drip in place, and check valves tight? F. Are Fire Dept. Connections visible, accessible and marked with ID signs? G. Have all the gauges, 5 or more years old, been replaced or calibrated? H. Has an internal inspection of the pipe, Check Valves and Strainers been performed within the last 5 years? J. Are all hoses and hose valves in good condition, free from physical damage and free of leaks? K. Hose (more than 5 years old) connected to the system has been service tested in accordance with NFPA 1962?
3 - CONTROL VALVES A. Are all sprinkler system main control valves and all other control valves in the appropriate open or closed position? B. Are all control valves supervised in the appropriate open or closed position?
(Circle Supervision Type)
Tamper, Chain Locked, Sealed
C. Were all control valves operated through full range of motion, lubricated and returned to normal position? D. Did all Electrical Supervisory switches actuate supervisory alarms? E. Are all control valves easily accessible and marked with ID signs? (Circle All That Apply) Location - Fire Pump Room, Riser Room, Vault
4 - WATER SUPPLY A. Did flow results have the same or greater PSI readings than previous tests? B. System water supplied from: Riser #
City Water
Size Static Residual Return Alarm PSI PSI PSI Time
Elevated Tank
Pressure Tank
Hydraulic Information Design Density
Design Area
PSI @ Base
(If NO, an Engineering Survey is required)
GPM Demand
Suction Tank
Pond
Other
Riser Size Static Residual Return Alarm # PSI PSI PSI Time
Hydraulic Information Design Density
Design Area
YES
5 - FLOW ALARMS
PSI @ Base
N/A
GPM Demand
NO
A. Did waterflow through the inspector’s test actuate all mechanical alarms? B. Did waterflow through the inspector’s test actuate all electrical alarms? C. Did the system have an external alarm device at the Riser - Electric or Mechanical (Circle All That Apply)
County Fire Protection, Inc. Water Based Inspection Form REV 3.0 01 March 2012
WMAG
Electric Bell
Water Based Page 1 of
SITE
Kroger (818)
DATE
6 - WET SYSTEMS - Provide Make and Model of Alarm Valves below Number of systems
Size
YES
N/A
NO
A. Alarm valves, riser check valves, gauges and associated trim are free from physical damage? B. Trim valves, alarm and supervisory lines are in the appropriate open or closed position? (Are Appropriate Signs provided) C. Location of Antifreeze System? D. The antifreeze tests indicate protection to
#1
#2
#3
#4
#5
degrees
#6
7 - DRY / PRE-ACTION / DELUGE SYSTEMS It is the owner’s responsibility to maintain auxiliary drains between inspections
Owner Notified
Number of Dry Systems
Make and Model
Trip test report attached
Trip test not required
Number of Pre-Action Systems
Make and Model
Trip test report attached
Trip test not required
Number of Deluge Systems
Make and Model
Trip test report attached
Trip test not required YES
N/A
NO
YES
N/A
NO
YES
N/A
NO
A. Valves, gauges and associated trim are free from physical damage? B. Trim valves, alarm and supervisory lines are in the appropriate open or closed position? C. Is the air pressure and priming water level normal? D. Did the air compressor operate satisfactory? E. Did the low air pressure alarm operate during the test? F. Auxiliary drains that were identified by the owner were drained during this inspection? G. Valves and trim appear to be protected from temperatures below 40OF? H. Pipe that passes through freezers is free of ice blockage?
8 - SPRINKLERS, PIPE, AND HANGERS A. Is all visible pipe in good condition with no external corrosion, physical damage and no leaks? B. Are visible pipe hangers and seismic braces free of physical damage? C. Are all sprinklers free of Physical Damage, free of Obstructions to Spray Patterns and free of Foreign Materials including Paint? D. Have all standard response sprinklers, 50 or more years old, been replaced or successfully tested? (NFPA 25 Chapter 5 for Testing Procedures) E. Have all fast response sprinklers, 20 or more years old, been replaced or successfully tested?
(NFPA 25 Chapter 5 for Testing Procedures)
F. Have all dry type sprinklers, 10 or more years old, been replaced or successfully tested?
(NFPA 25 Chapter 5 for Testing Procedures)
9 - FIRE PUMPS AND STORAGE TANKS Fire Pump on System: YES
NO
Pump Test Performed This Inspection: YES
NO
Report Attached: YES
NO
N/A
A. Are gravity, surface or pressure tanks at the proper pressure and/or water levels? B. Storage tank water appears to be protected from temperatures below 40OF? C. Are the storage tank exterior structure, ladders, and foundation free from physical damage? D. Storage tank exterior is free from corrosion and signs of degradation? The dry system(s) at this location were full flowed per requirements. We fully drained the water to the best of our ability, but we are not responsible for design flaws that MAY previously exist that are out of our control.
Explanation of “NO” answers, system deficiencies, and/or inspector recommendations are listed on SERVICE FOLLOW UP # attached to this form.
, which is
No SERVICE FOLLOW UP REPORT was required during this inspection. state that the information on this formatisthe correct atplace the time placeAll ofequipment this inspection. All tests and performed in accordance with I Istate that the information on this form is correct time and of thisand inspection. tested at this time was leftinspections in operational were condition upon completion of this inspection applicable NFPA test and inspection sections. All equipment tested at thistotime was to leftonly in those operational upon completion inspection except except as noted on any25 SERVICE FOLLOW UP REPORT as stated above. All conditions noted are limited that couldcondition be readily observed from the floorofatthis the time of inspection. This inspection limited to a visual and functional thestated Fire Suppression as noted onisany SERVICE FOLLOW UP inspection REPORTofas above. System only. No inspections have been conducted or representations made regarding the conditions or adequacy of Sprinkler System Design or other equipment not listed in this report. A review of the design, layout and engineering of the Fire Sprinkler System is outside the scope of this inspection and has not been performed. Name of Inspector
C.Shoemaker II
Signature
Certification #
I acknowledge that the inspection, deficiencies, and suggested improvements were discussed with me upon completion of the inspection. It is understood that all information contained herein is provided to the best of the knowledge of the person providing the information and that, if requested, will be forwarded to the authority having jurisdiction. Name of Owner or Representative
Signature
Water Based Page 2 of
County Fire Protection, Inc. Water Based Inspection Form REV 3.0.01 March 2012
Monthly Quarterly Semi Annual Annual
County Fire Protection, Inc.
2937 Switzer Ave. Columbus, Ohio 43219 Phone 614-252-6630 Fax 614-252-6640 Customer Kroger 818 Bethel Rd Address 2090 Bethel Road City/State Columbus Contact Phone (614) 326-5645
4620 Crystal Parkway Kent, Ohio 44240 Phone 330-673-3600 Fax 330-673-1600
OH
ManufacturerSilent Knight Model # SK-5208 No. of circuits Style Revision# Install date Date last serviced Monitored Y N Company Acct # Phone# Digital City Box Reverse Polarity Radio Other System Controls Control panel Yes No N/A Interface equipment Yes No N/A Lamps/LEDs Yes No N/A Fuses Yes No N/A Primary power supply Yes No N/A Trouble signals Yes No N/A Disconnect switch Yes No N/A Ground fault Yes No N/A Primary voltage Amps Disconnect location Locked Battery voltage Amp hrs Battery type Sealed Lead Dry Cell Ni Cad Other Date Battery condition Good Fair Poor Charger operable Yes No N/A Automatic switch over Yes No N/A Engine driven generator Yes No N/A Fuel storage location Alarm Initiating Devices Manual stations Ion smoke detectors Photo smoke detectors Duct detectors Heat detectors Waterflow switches Supervisory switches Kitchen system Suppression system Other
Functional Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Alarm Indicating Devices Bells Horns Horn strobes Strobes Sirens Speakers Speaker strobes Chimes Lights Deficiencies found
Functional Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Date 01/18/2016 08:00am EST, 01/ Man Hrs.
812 Warehouse Road, Unit D Toledo, Ohio 43615 Phone 419-535-0955
Emergency Communications Equipment Functional Phone sets Yes No Phone jacks Yes No Off hook indicator Yes No Amplifiers Yes No Tone generator Yes No Call in signals Yes No System performance Yes No Remote annunciators Yes No Supervising Station Monitoring Alarm signal Yes Alarm restoration Yes Trouble signals Yes Trouble restoral Yes Supervisory signals Yes Supervisory restoral Yes
No No No No No No
Notification of Testing Monitoring entity Building occupants Building management Other
Yes Yes Yes Yes
No No No No
Impairments reported AHJ Building management
Yes Yes
No No
System returned to normal
Yes
No
Count N/A N/A N/A N/A N/A N/A N/A N/A Time
Date Time
Comments
Count N/A N/A N/A N/A N/A N/A N/A N/A N/A * System Tested in Accordance with NFPA Standards Count N/A N/A N/A N/A N/A N/A N/A N/A N/A
Technician Charles Shoemaker, Bill Henderson Signature State License Number Name of owners rep Signature Other representative Signature
4620 Crystal Parkway Kent, Ohio 44240 phone 330-673-3600 fax 330-673-1600
812 Warehouse Rd., Unit D Toledo, Ohio 43615 phone 419-535-0955 fax 419-380-8650
2937 Switzer Ave. Columbus, Ohio 43219 phone 614-252-6630 fax 614-252-6640
35169 E Michigan Ave #164 Wayne, MI 48184 toll free 1-888-528-0928
WATER BASED FIRE PROTECTION INSPECTION & TEST REPORT
www.county-fire.com
01/18/2016 08:00am EST, 01/28/2016 08:00am EST Kroger 818 Bethel Rd SITE CONTACT (614) 326-5645 PHONE ADDRESS 2090 Bethel Road Columbus OH CITY STATE DATE
This inspection is:
Annual
Semi-Annual
Quarterly
Monthly
Weekly
Other
This section is to be answered by the Owner or Representative
1 - OWNERS SECTION
YES
N/A
NO
YES
N/A
NO
YES
N/A
NO
YES
N/A
NO
A. Is the building occupied? B. Has the occupancy classification and hazard of contents remained the same since the last inspection?
(If NO, an Engineering Survey is required)
C. Are all the fire protection systems in service? D. Has the system remained in service without modification since the last inspection? E. Was the system free of actuation of devices or alarms since the last inspection?
(Water Flow Alarms and Supervisory Alarms)
F. Are all Wet Sprinkler System piping and Wet portions of Dry Systems protected from temperatures below 40° F?
2 - GENERAL A. Have the sprinkler systems been extended to all visible areas of the building?
(If NO, an Engineering Survey is required)
B. Does there appear to be proper clearance between the top of all storage and the sprinkler deflector? C. Are the hydraulic nameplate(s) securely attached to the riser and legible?
(Answer N/A if system is Pipe Scheduled)
D. Is there a spare head box with the proper number and type of spare sprinklers and wrenches? E. Are Fire Dept. Connections in satisfactory condition, couplings free, caps / plugs in place, ball drip in place, and check valves tight? F. Are Fire Dept. Connections visible, accessible and marked with ID signs? G. Have all the gauges, 5 or more years old, been replaced or calibrated? H. Has an internal inspection of the pipe, Check Valves and Strainers been performed within the last 5 years? J. Are all hoses and hose valves in good condition, free from physical damage and free of leaks? K. Hose (more than 5 years old) connected to the system has been service tested in accordance with NFPA 1962?
3 - CONTROL VALVES A. Are all sprinkler system main control valves and all other control valves in the appropriate open or closed position? B. Are all control valves supervised in the appropriate open or closed position?
(Circle Supervision Type)
Tamper, Chain Locked, Sealed
C. Were all control valves operated through full range of motion, lubricated and returned to normal position? D. Did all Electrical Supervisory switches actuate supervisory alarms? E. Are all control valves easily accessible and marked with ID signs? (Circle All That Apply) Location - Fire Pump Room, Riser Room, Vault
4 - WATER SUPPLY A. Did flow results have the same or greater PSI readings than previous tests? B. System water supplied from: Riser #
City Water
Size Static Residual Return Alarm PSI PSI PSI Time
Elevated Tank
Pressure Tank
Hydraulic Information Design Density
Design Area
PSI @ Base
(If NO, an Engineering Survey is required)
GPM Demand
Suction Tank
Pond
Other
Riser Size Static Residual Return Alarm # PSI PSI PSI Time
Hydraulic Information Design Density
Design Area
YES
5 - FLOW ALARMS
PSI @ Base
N/A
GPM Demand
NO
A. Did waterflow through the inspector’s test actuate all mechanical alarms? B. Did waterflow through the inspector’s test actuate all electrical alarms? C. Did the system have an external alarm device at the Riser - Electric or Mechanical (Circle All That Apply)
County Fire Protection, Inc. Water Based Inspection Form REV 3.0 01 March 2012
WMAG
Electric Bell
Water Based Page 1 of
SITE
Kroger (818)
DATE
6 - WET SYSTEMS - Provide Make and Model of Alarm Valves below Number of systems
Size
YES
N/A
NO
A. Alarm valves, riser check valves, gauges and associated trim are free from physical damage? B. Trim valves, alarm and supervisory lines are in the appropriate open or closed position? (Are Appropriate Signs provided) C. Location of Antifreeze System? D. The antifreeze tests indicate protection to
#1
#2
#3
#4
#5
degrees
#6
7 - DRY / PRE-ACTION / DELUGE SYSTEMS It is the owner’s responsibility to maintain auxiliary drains between inspections
Owner Notified
Number of Dry Systems
Make and Model
Trip test report attached
Trip test not required
Number of Pre-Action Systems
Make and Model
Trip test report attached
Trip test not required
Number of Deluge Systems
Make and Model
Trip test report attached
Trip test not required YES
N/A
NO
YES
N/A
NO
YES
N/A
NO
A. Valves, gauges and associated trim are free from physical damage? B. Trim valves, alarm and supervisory lines are in the appropriate open or closed position? C. Is the air pressure and priming water level normal? D. Did the air compressor operate satisfactory? E. Did the low air pressure alarm operate during the test? F. Auxiliary drains that were identified by the owner were drained during this inspection? G. Valves and trim appear to be protected from temperatures below 40OF? H. Pipe that passes through freezers is free of ice blockage?
8 - SPRINKLERS, PIPE, AND HANGERS A. Is all visible pipe in good condition with no external corrosion, physical damage and no leaks? B. Are visible pipe hangers and seismic braces free of physical damage? C. Are all sprinklers free of Physical Damage, free of Obstructions to Spray Patterns and free of Foreign Materials including Paint? D. Have all standard response sprinklers, 50 or more years old, been replaced or successfully tested? (NFPA 25 Chapter 5 for Testing Procedures) E. Have all fast response sprinklers, 20 or more years old, been replaced or successfully tested?
(NFPA 25 Chapter 5 for Testing Procedures)
F. Have all dry type sprinklers, 10 or more years old, been replaced or successfully tested?
(NFPA 25 Chapter 5 for Testing Procedures)
9 - FIRE PUMPS AND STORAGE TANKS Fire Pump on System: YES
NO
Pump Test Performed This Inspection: YES
NO
Report Attached: YES
NO
N/A
A. Are gravity, surface or pressure tanks at the proper pressure and/or water levels? B. Storage tank water appears to be protected from temperatures below 40OF? C. Are the storage tank exterior structure, ladders, and foundation free from physical damage? D. Storage tank exterior is free from corrosion and signs of degradation? The dry system(s) at this location were full flowed per requirements. We fully drained the water to the best of our ability, but we are not responsible for design flaws that MAY previously exist that are out of our control.
Explanation of “NO” answers, system deficiencies, and/or inspector recommendations are listed on SERVICE FOLLOW UP # attached to this form.
, which is
No SERVICE FOLLOW UP REPORT was required during this inspection. state that the information on this formatisthe correct atplace the time placeAll ofequipment this inspection. All tests and performed in accordance with I Istate that the information on this form is correct time and of thisand inspection. tested at this time was leftinspections in operational were condition upon completion of this inspection applicable NFPA test and inspection sections. All equipment tested at thistotime was to leftonly in those operational upon completion inspection except except as noted on any25 SERVICE FOLLOW UP REPORT as stated above. All conditions noted are limited that couldcondition be readily observed from the floorofatthis the time of inspection. This inspection limited to a visual and functional thestated Fire Suppression as noted onisany SERVICE FOLLOW UP inspection REPORTofas above. System only. No inspections have been conducted or representations made regarding the conditions or adequacy of Sprinkler System Design or other equipment not listed in this report. A review of the design, layout and engineering of the Fire Sprinkler System is outside the scope of this inspection and has not been performed. Name of Inspector
C.Shoemaker II
Signature
Certification #
I acknowledge that the inspection, deficiencies, and suggested improvements were discussed with me upon completion of the inspection. It is understood that all information contained herein is provided to the best of the knowledge of the person providing the information and that, if requested, will be forwarded to the authority having jurisdiction. Name of Owner or Representative
Signature
Water Based Page 2 of
County Fire Protection, Inc. Water Based Inspection Form REV 3.0.01 March 2012
