Report of Inspection

of Water Based Fire Protection Systems

Inspecting Agency: Inspector : Inspection Contract#: 37521
Information Section

Date of Inspection: Completed By:

Occupant Business Name:
Street Address:
City: State: Zip:
Phone: Fax:
Position: Authority to approve work? Y YES N/A N

Name of Property Owner:

Property Owners Address:
City: State: Zip: 1
Phone: Fax:
Responsible Party Name: Position:
Name of Supervisory Alarm Company:
Date of last inspection: Prior Inspector’s name:
Y N/A N
1. All prior inspection reports, logs and test data are available for review:
2. Plans of systems on site for review?
3. Modifications made to systems fully reviewed and documented?
4. Reports of sprinkler action fully reviewed and documented?
5. Copy of NFPA 25 on life?
6. Weekly logs on inspections required by NFPA 25 on life?
7. In the occupation and hazard the same reported on last inspection? NO
8. All deficiencies reported last inspection corrected?

9. MS data sheets reviewed and hazards to inspector removed?

(Use separate sheet for additional information as may be needed. All “NO” answers to be fully explained)
Form 9A-104A should be completed by the Inspecting Firm/Contractor and provided to the Owner.

Comments:

The owner and/or designated representative acknowledge the responsibility of the operating condition of the
component parts at the time of this inspection. It is agreed that the inspection service provided by the contractor as
prescribed herein is limited to performing a visual inspection and/or routine testing and any investigation or unscheduled
testing, modification, maintenance, repair etc. of the component parts is not included as part of the inspection work
performed. It is further understood that all information contained herein is provided to the best of the knowledge of the
party providing such information.

Date:

Owner/designated representative:
Date:

Inspector’s Signature:
 ATTENTION: The American Fire Sprinkler Association (AFSA) is a non-profit trade association. AFSA does not guarantee, certify,
underwrite, or pre-approve any services provided by AFSA. Our logo is only advertisement, Warnings disclaimers, and update information
exist on the back of the form. It is your responsibility to read these statements.
 Report of Inspection
of Water Based Fire Protection Systems
Inspecting Firm (Contractor) Inspection Contract# 3
Information Section

Street Address:
Ctiy: State: Zip:
Phone: Fax:
Inspector Name: Date:
Property Name: (refer to Form 103A)

This report contains information resulting from a visual inspection of the following type of Water Based Fire Protection
Systems: (please check all that apply)

Form Description Form #

Report of Inspection (Information Section) 103A Cover sheet
Report of Inspection (Inspectior’s Section) 104A Cover sheet
Weekly report on inspection 105A No. of systems
Wet pipe fire sprinkler system – inspection/testing/maintenance 106A No. of systems
Dry pipe fire sprinkler system - inspection/testing/maintenance 107A No. of systems
Wet standpipe system - inspection/testing/maintenance 108A No. of risers
Dry pipe standpipe system - inspection/testing/maintenance 109A No. of risers
Fire pump - inspection/testing/maintenance 110A No. of risers
Underground fire main - inspection/testing/maintenance 111A -----------------------------
Water reservoir, tank, pond, etc. - inspection/testing/maintenance 112A Reservoir cap
Preaction fire protection system - inspection/testing/maintenance 113A No. of systems
Deluge fire protection system - inspection/testing/maintenance 114A No. of systems
Water – foam fire protection system - inspection/testing/maintenance 115A No. of systems
Foam fire protection system - inspection/testing/maintenance 116A No. of systems
Other components description.

NOTE: The scheduled of visual inspection of to the performed as indicated below. The inspector is to complete all
questions and review the result of this inspections and recommendations, corrections, testing, maintenance, etc. with
the owner.
All “NO” answers are to be fully explained in detail.

Scheduled inspection: (circle one) Weekly: Monthly: Quarterly: Annually:

Recommendations:

NOTE: There are scheduled periodic testing and maintenance task that must be conducted for the continuous reliability
of the fire protection system. These should be performed at the intervals indicated in NFPA 25 standard. This information
is being provided as a matter of courtesy. These tasks only be performed by property trained personnel using proper
equipment.

The owner’s or designated representative’s signature shall be obtained acknowledging receipt of this report.
(Each page shall be initialed and dated by the owner or designated representative and inspector.
Owner/designated representative: Date:

Inspector’s Signature: Date:

ATTENTION: The American Fire Sprinkler Association (AFSA) is a non-profit trade association. AFSA does not guarantee, certify, underwrite, or pre-
approve any services provided by AFSA. Our logo is only advertisement, Warnings disclaimers, and update information exist on the back of the form. It is your
responsibility to read these statements.

Report of Inspection
of Water Based Fire Protection Systems
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO BE FILLED.
This form is being offered to assist in the performance and recording of the results of Weekly Scheduled Inspection Tasks of the
various type of Fire Sprinkler Systems and component parts as listed below.

Inspecting Firm:
Name of Property:
Inspector Name:
Page of Date:

Wet Sprinkler and Standpipe Systems: Dry Pipe Sprinkler System:

A-1.1 Spkr. Supply gauge: 25 psi B-1.1 Air pressure gauge: psi ( n/a)
A-1.2 Spkr. System gauge: 100 psi B-1.2 Accelerator gauge: psi (n/a)
A-1.3 Stpipe supply gauge: 100 psi B-1.3 Water pressure gauge: psi (n/a)
A-1.4 Stpipe system gauge: 100 psi Y N/A N
A-1.5 Stpipe (top flr.) gauge: 90 psi B-2.0 System in service on inspection:
Y N/A N B-2.1 Compressor operational:
A-2.0 System in service on inspection: B-2.2Oil level full:
A-2.1 Spkr. control valve sealed open: B-3.1 Control valve sealed open:
A-2.2 Stpipe control valve sealed open: B-3.2 Control valves accessible:
A-3.1 Trim piping leak tight: B-3.3 Alarm testvalve closed:
A-4.1 Backflow asmb. valves sealed open: B-3.4 Alarm line valve open:
A-5.1 Control valves accessible: B-4.1 Intermediate chamber leak tight:
A-8.1 Signage/identification tags in place: B-4.2 Low point drum drips drained:
A-9.1 Alarm panel clear: (as frequently as needed)
A-9.2 Systems left in service: B-5.1 Valve enclosure secured:
A-10.1 Comments: B-5.2 Low temperature alarm operational:
1.) Good operating Condition B-5.3 Heater operational:
B-8.1 Signage/identification tags in place:
B-9.1 Alarm panel clear:
A-9.2 Systems left in service:

The inspection task noted with an asterisk (*) are required to be performed on a monthly frequency schedule, however
due to varying conditions that may exist on any individual project, it is suggested that these tasks be performed on a weekly
frequency schedule.

Fire Department Connection Sprinkler Heads

Y N/A N Y N/A N
*C-1.1 Caps or plugs of FDC: *D-1.1 Extra heads in spare head cabinet:
*C-1.2 Swivel rotation nonbinding: *D-1.2 Heads appear of proper temperature:
*C-2.1 FDC location plainly visible: *D-1.3 Head wrench for each type of head:
*C-2.2 FDC easily accessible: *D-2.1 Head in cooler appears free of ice, corrosion:
 *C-2.3 FDC identification plate in place: *D-2.2 Head appears free of leakage or damage
*C-3.1 Ball drip drain leak tight: *D-2.3 Head appears free of paint:
*C-4.1 Wall hydrant plainly visible: *D-2.4 Heads appear free of non-approved coverings:
*C-4.2 Wall hydrant easily accessible: *D-3.1 Standard head less than 50 year:
*C-4.3 Wall hydrant identification plate in place: *D-3.2 Residential head less than 20 year:
*C-10.1 Comments: *D-3.3 Fast response heads 20 year:
1.) Good operating condition *D-3.4 High temperature heads 5 year:
*D-10.1 Comments:
1.) Good operating condition

(All “NO” answers to be fully explained)

Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date:

Report of Inspection
of Water Based Fire Protection Systems
Monthly Items to be Reviewed
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO BE FILLED.
(Montly Inspection tasks are included in this report)
(There is not scheduled monthly testing task requirement. See the quarterly schedule)

Inspecting Firm: Inspection contract#

Name of Property:
Inspector Name: Date:
Page of
Inspection Frequency: Monthly Quarterly Annually Other:

Wet Sprinkler System Inspection

A-1.1 Spkr. supply gauge: Y N/A N
A-1.2 Spkr. System gauge: A-9.1 FDC plainly visible:
Y Yes N A-9.1 FDC easily accessible:
A-2.0 Systems in service on inspection: A-9.5 FDC swivels non-binding rotation:
A-2.1 Spkr. control va. Locked/tamper open: A-9.6 FDC caps/plugs and place:
A-2.2 Stpipe control va. Locked/tamper open: A-9.7 FDC gaskets/sign in place:
A-2.3 Backflow va. Locked/tamper open: A-9.10 FDC check valve drip free:
A-2.4 Anti-freeze system va. Locked/tamper A-9.11 FDC ball drip drain drip free:
open: A-10.1Exterior alarms properly identified:
A-2.8 Tamper switches appear operational: A-10.2 Exterior alarms appear operational:
A-3.1 Valve area accessible : A-10.3 Interior alarms appear operational:
A-3.2 Control valves accessible: A-11.1 Extra heads in spare head cabinet
A-4.1 Pressure regulating valve is open: A-11.2 Head appear of proper temperature:
A-4.2 Pressure regulating valve in good A-11.3 Head wrench for each type of head:
 condition: A-11.6 Head in cooler appears free of ice
corrosion:
A-4.3 Pressure reg. valve leak tight: A-11.7 Head appears free of leakage or
damages:
A-4.4 Pressure reg. va. maintaining down- A-11.8 Head appears free of paint:
stream pressure per design criteria: A-11.9 Heads appear of free of non-approved
coverings:
A-5.1 Pressure relief va. in closed position A-12.0 Standard head less than 50 year:
except when operational: A-13.0 Residential head less than 20 year
A-5.2 Pressure relief va. in good condition: A-14.0 Watt hydrant plainly visible:
A-5.3 Pressure relief va. leak tight: A-14.1 Watt hydrant easily accessible:
A-5.4 Pressure relief va. maintaining up- A-14.2 Watt hydrant identification plate in
stream pressure per design criteria: place:
A-15.1 Hose/hydrant house free of damage:
A-6.1 Main check valve holding pressure: A-15.2 Hose/hydrant house fully equipped:
A-6.2 Alarm check va. exterior free of A-15.3 Hose/hydrant house is accessible:
damage:
A-6.3 Water flow switch operational: A-16.1 Wet pipe areas appears properly
healed:
A-7.1 Trim piping leak tight: A-17.0 Alarm panel clear:
A-7.2 Retard chamber drip tight: A-18.0 System left in service:
A-7.3 Alarm drain drip tight when not operational: A-20.0 Comments
A-8.1 Trim valves in appropriate position:
A-8.2 Alarm test line valve closed: 1.) Everything is in good condition.

(All “NO” answers to be fully explained)

Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date:
 Report of Inspection

of Water Based Fire Protection Systems

Monthly Items to be Reviewed
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO BE FILLED.

Inspecting Firm: Inspection contract# 37521

Name of Property:
Inspector Name: Date:
Page of
Inspection Frequency: Monthly Quarterly Annually Other:

Monthly Report of Inspection of Monthly Testing Requirements

Wet Sprinkler System for Wet Sprinkler System
(For a quarterly inspection, complete all items list on FORM 94- Y N/A N
106A “Report of Inspection—Monthly items to be Reviewed “AND” C-1.1 Main drain flow test with 2 ½” _inch
items listed below) valve full open:
C-2.1 Spkr. supply gauge: psi
C-2.2 Spkr. supply gauge main drain flow: psi
Y Yes N C-3.1 Spkr. system gauge: psi
B-1.1 Hydraulic nameplate attached: C-3.2 Spkr. system gauge with main drain
B-1.2 Straines and filters cleaned: flow: 100 psi
B-1.2 Exterior alarms properly identified:
B-2.0 Alarm panel clear: C-4.1 Water flow alarm devices activated:
B-3.0 System left in service: C-4.2 Interior building alarm operating:
B-20.0 Comments: C-4.3 Exterior alarms operating:
1.) Good operating condition. C-5.1 Inspectors test flow:
C-6.1 Time to ring alarm from alarm check
valve:
C-7.1 Time to ring alarm from flow switch: .
C-8.1 Time to ring alarm from pressure switch: : .
Y N/A N
C-9.1 Gauges appear operating properly:
C-10.1 Did alarm supervisory company
receive signal properly.
C-10.2 Did alarm panel reset properly:
C-11.0 Alarm panel clear:
C-12.0 System left in service:
C-20.0 Comments:
1.) Good Operating condition.

Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date:

 Monthly Report of Inspection of Monthlyl Testing & Maintenance Tasks that are
Wet Sprinkler System are in Addition to Other Frequency
(Description of this form: These tasks are in addition to the monthly and quarterly Tasks – For Wet Sprinkler System
tasks. Complete the monthly and quarterly reports AND this report as required for a
total annual report of inspection. Visual inspection is defined as what can be Y N/A N
observed from the floor level by an inspector. The use of binoculars is
recommended for visual inspections in high buildings.) E-1.1 Control valve lubricated:
Y N/A N E-2.1 Control valve operated to closed
position and returned to open position:
D-1.1 Prior to freezing season, owner is F-1.1 Backflow assemble valve operated and
responsible for building to be in secure returned to open position.
condition and properly heated:
D-2.1 Visual inspection:hanger/seismic F-1.2 Backflow assemble valve operated and
bracing appear attached and secure: returned to open position.
D-3.1 Visual inspection “exposed” piping G-1.1 Post indicator valve returned to open
appear position:
in good condition: (Valves left ¼ turn from wide open)
D-3.2 Piping appear free of mechanical H-1.1 Antifreeze solution checked to provide
damages: adequate freeze protection:
(protection temp:______°F)
D-3.3 Piping appears free of leakage:
D-3.4 Piping appears free of corrosion: Test Frequency items of 5 Years of Greater
D-3.5 Piping appears properly aligned: H-2.0 Internal inspection last date ( 5years) ____NO
D-3.6 Piping appears free of external loads: H-2.1 Alarm check valve:
D-4.1 Sprinkler appear free of corrosion: H-2.15 Flow tested pressure regulating
Control valves:
D-4.2 Sprinkler appear properly positioned: H-2.2 Make: SYSTEM SENSOR
D-4.3 Sprinkler appear properly spaced: H-2.3 Model 09281
D-4.4 Sprinkler appear free of foreign H-2.4 Size: 4 INCH Date: 4/2002
materials:
D-4.5 Sprinkler spray patterns appear free of H-2.5 Check valve:
obstructions:
D-10.0 Alarm panel clear: H-2.6 Strainers:
D-11.0 System in service: H-2.7 Filters:
D-20.0 Comments: H-2.8 Trim orifices:
1.) Good operating condition. H-2.9 Other:
H-3.0 Gauge maintenance: date last tested
five years.
H-3.1 Replaced date:
J-1.0 Sprinkler maintenance test:
(5 year)
J-1.1 High temp. date:__________
(20 year then 10 year thereafter)
J-1.2 Fast response date: ________
J-1.3 Residential head 20 year:
(50 year then 10 year thereafter)
‘’’’’Provide additional pages if necessary to record the: J-1.4 Standard sprinkler date:___________
Volume of flow______gpm. J-20.0 Comments:
Supply side pressure_ ____psi 1.) Good operating condition.
System side pressure_______psi

(All “NO” answers to be fully explained)

Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date:
 Report of Inspection & Testing
of Fire Protection Systems
Report of Internal Condition of Sprinkler Piping
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO BE FILLED.

Inspecting Firm: (Contractor) Inspection contract# 37521

Name of Property:
Inspector Name: Date:
Page of Date of previous internal pipe inspection:
Inspection Frequency: Monthly Quarterly Annually Other:
Identify System(s) involved: Wet Dry Preaction Deluge Other:

An examination of representative sections of this sprinkler system has been made to determine internal conditions.

Initial Examination Data:

Number of branch lines examined: 95% % of total branch lines : 95%
Number of cross mains examined: 95% % of bulk lines 95%
Others points examined (Described): None

Results of Initial Examination:

(Check the box which applies)
1. The interior of the sprinkler piping appears in satisfactory condition:
2. 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 i.e pipe scale, silt, mud, tuberculation)
 Scale, muds, rusts, etc.

Examination Subsequent of Cleaning System:

Cleaning method used (described) : FLUSHING
Number of branch lines examined: 95% % of total branch lines : 95%
Number of cross mains examined: 95% % of bulk lines : 95%
Others points examined (Described: None

Result of Examination Subsequent of Cleaning System:

(Check the box which applies)
1. The interior of the sprinkler piping appears in satisfactory condition:
2. If interior of piping other than satisfactory, describe:

Signature and titel of person conducting cleaning : Date of Cleaning

Witness (over of lessee of the property) :

(All “NO” answers to be fully explained)

Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date:
 Report of Inspection
of Wet Standpipe Systems
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO BE FILLED.

Inspecting Firm: (Contractor) Inspection contract#

Name of Property:
Inspector Name: Date:
Page of Date of previous internal pipe inspection: NONE
Inspection Frequency: Monthly Quarterly Annually Other:

A-1.1 Supply water gauge ; Y N/A N

A-1.2 System water gauge: : A-6.12 Roof manifold control valve closed:
A-1.3 Top floor gauge: A-7.1 Tamper switches appear operational:
A-1.6 Class of service: I II III A-7.2 Alarm devices appear operational:
A-2.1 Hose valve size: A-7.5 Exterior of devices in good condition:
A-2.2 Hose valve with adapter size: 4” x 1 ½”in A-7.6 Exterior bells, gangs unobstructed:
A-2.3 Type and size of nozzle: A-7.7 Exterior fittings free of water leakage:
Adjustable : 1 ½”in Main drain:
Straight stream : 1 ½”in Alarm bell line:
Fog : 1 ½’in A-8.1 Hose valve free of physical damage:
Non-adjustable 1 ½”in A-8.2 Hose valve outlet with cap.
A-3.1 Indicate the type and record the information for the A-8.3 Hose valve outlet thread in good
TOP FLOOR hose valve: condition:
Pressure reducing valves inlet pressure set ; 90 psi A-8.6 System free of visible water leaks:
Pressure reducing valves outlet pressure set: 100psi A-8.8 Hose valve outlets equipped with
reducing hose adapter:
Pressure restricting valves inlet pressure set 100psi A-9.1 Inspection of cabinet per NFPA 1962:
Pressure reducing valves outlet pressure set_ 100psi A-9.2 Inspection of hose per NFPA 1962:
Pressure regulating valves inlet pressure set_100 psi A-9.3 Inspection of hose nozzle per NFPA 1962:
Pressure regulating valves outlet pressure set 100psi A-9.6 Wall penetrations caulked/sealed:
(Attached supplemental sheet recording the gpm and A-10.1 Roof manifold equipped with hose
pressure settling for EACH FLOOR hose valve) valves:
A-10.2 Roof manifold hose valve caps in place:
Y N/A N A-10.3 Roof manifold hose swivel rotation is
A-4.1 System in service on inspection: nonbinding:
A-4.2 System equipped with flow switch: A-10.4 Roof manifold valves good condition:
A-4.3 System equipped with alarm check A-10.5 Roof manifold ball drip operational:
valve:
A-4.4 Trim piping leak tight: A-11.1 Caps or plugs on FDC:
A-5.1 Control valve sealed open: A-11.2 FDC swivel rotation nonbinding:
A-5.2 Control valves locked/tamper open: A-11.3 FDC location plainly visible:
A-5.6 Backflow asmb. valves sealed open: A-11.4 FDC easily accessible:
A-5.7 Backflow asmb. locked/tamper open: A-11.5 FDC identification plate in place:
A-5.8 Backflow assembly operating OK A-12.1 Piping free of physical damage:
 A-6.1 Wall hydrant sealed open: A-12.2 Piping (exterior) is free of corrosion:
A-6.2 Wall hydrant locked/tamper open: A-12.3 Piping appears to be leak tight:
A-6.6 Valve area clear of obstructions: A-12.6 Ball drip drain drip tight:
A-6.7 Valve area accessible: A-12.7 Main drain at suppl 2 ½”(in): 105psi
A-6.9 Wall hydrant plainly visible: A-12.9 Signage/identification plates in place:
A-6.10 Wall hydrant plainly visible: A-15.1 Alarm panel clear:
A-6.11 Wall hydrant identification plate in place: A-15.2 All system in service:
A-16.1 Comments:

(All “NO” answers to be fully explained)

Inspector’s Initial_: RMT Owner/designated rep. initial_________________ Date:

Report of Inspection, Testing & Maintenance of Wet Standpipe System….continued:

Mothly Testing of Wet Five Year Testing

Standpipe System
Y N/A N Y N/A N
B-1.1 Main drain 2 ½”(in.) flow at riser: 100 E-1.1 Pressure gauges calibrated:
psi Date: 01/2016
B-2.1 Alarm devices operated: E-1.2 Pressure gauge replace:
Date: 01 / 2016
Refer to NFPA 1962 for testing of standpipe system E-2.2 Water supply test performed:
in addition to the task indicated herein. Date: 03/2016
E-3.1 Pressure regulating type hose valves
Annual Testing flow tested: Date; 03/2016
Y N/A N
C-1.1 Test of hose per NFPA 1962: (Attach additional pages to record the results of the flow test
C-1.2 Test of hope nozzle per NFPA 1962: information indicated below which shall be provided for each
type of hose valve connection including the root manifold, for
Five Year Inspection each floor and for each standup riser. The authority having
jurisdiction shall be consulted prior to conducting the flow test.)

Y N/A N Y N/A N
D-1.1 Internal Inspection of check valves: E-4.1 Volume of flow: 150 gpm
Date: 01/2016 E-4.2 Supply side:_105psi
D-1.1 Internal inspection of alarm check: E-4.3 Hose connection side: 100 psi
Date: 01/2016

(All “NO” answers to be fully explained)

Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date:
 Report of Inspection, Testing,
& Maintenance
of Fire Pumps
The following inspection, testing, and maintenance tasks are to be performed at the indicated
frequencies. The required weekly tasks are also included on this list.
ALL QUESTIONS ARE TO BE FULLY ANSWERED AND ALL BLANKS TO BE FILLED.
Firm: Inspection contract# :
Name of Property:
Inspector Name: Date:
Page of

Fire Pumps

Y N/A N Y N/A N
A-1.0 Inspection of Pump Enclosure: A-5.0 Diesel Pumps – Semiannual Inspection
and Maintenance
A-1.1 Pump enclosure secured: A-5.1 Test antifreeze protection level
A-1.2 Pump enclosure heated (40° F if diesel A-5.2 Inspect flexible exhaust section:
engine equipped with engine heater):
A-1.3 Pump enclosure heated (70° F if diesel A-5.3 Check and test operation of safeties
engine not equipped with engine heater and alarms
A-1.4 Vent louvers operate: A-5.4 Clean boxes panels and cabinets:
A-1.5 Vent louvers intake dust clean:
A-1.6 Pump enclosure adequately lighted: A-6.0 Maintenance to be Performed
Annually or as indicated:
A-6.1 Lubrication of bearings performed
A-2.0 Electrical Pumps – Monthly Inspection A-6.2 Lubrication of coupling performed
and Maintenance
A-2.1 Isolating switch and circuit breaker A-6.3 Lubrication of right angle gear performed:
exercised:
A-2.2 Inspect check clean and test circuit A-6.4 Lubrication of motor bearings performed:
breakers: (replace as needed )
(replace date: JAN. 2016)
A-7.1 Accuracy of pressure switch setting
A-3.0 Diesel Pumps – Monthly Inspection A-7.2 Calibrate pressure switch setting
and Maintenance
A-3.1 Inspect and remove corrosion, battery A-8.1 Change oil (50 hours of operation)
case exterior clean and dry:
A-3.2 Test specific or state of charge A-8.2 Change oil filter (50 hours of operation
A-3.3 Inspect charger and charger rate: A-17.0 Fire pump controller in service:
A-3.4 Check equalize charge: A-18.0 Jockey pump controller in service:
A-19.0 Alarm panel clear:
A-4.0 Diesel Pumps – Monthly Inspection A-20.0 System in service:
and Maintenance
A-4.1 Service fuel strainer, filter and/or dirt leg: A-21.0 Comments:
A-4.2 Clean or replace crankcase breather: 1.)
A-4.3 Check and clean water strainer:
A-4.4 Inspect insulation and fire hazards:
A-4.5 Inspect and check wire chafing where
subject to movement:
 (All “NO” answers to be fully explained)
Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date:
 Report of Inspection, Testing, & Maintenance of Fire Pumps . . . . continued

Y N/A N Y N/A N
B-1.0 Annual Inspection of Hydraulic B-3.0 Annual Inspection of Diesel
System Engine System:
B-1.1 Suction pressure gauge: B-3.1 Diesel tank ⅔ full
B-1.2 Discharge pressure gauge: B-3.2 Batteries fully charged:
B-1.3 Pump starting pressure: B-3.3 Battery charger operating properly
B-1.4 Suction line control valves sealed open: B-3.4 Battery terminal clean
B-1.5 Discharge line control valves sealed open: B-3.5 Battery state of charge checked:
B-1.6 By-pass line valves sealed open: B-3.6 Battery pilot lights “ON”:
B-1.7 All control valves accessible: B-3.7 Battery failure pilot lights “OFF”:
B-1.8 Suction reservoir full B-3.8 Electrolyte level in batteries normal:
B-1.9 Shaft seals dripping water property B-3.9 All alarm pilot lights “OFF”:
(1 drop per second)
B-1.10 System free of vibration or usual noise B-3.10 Engine running time meter recording
pump operation properly:
B-1.11 Packing boxes, bearings, pump casing B-3.11 Oil level in right angle gear drive normal
free of overheating:
Comments: B-3.12 Diesel engine oil level full:
B-3.13 Diesel engine water level full:
1.) Everything is in good condition. B-3.14 Water jacket heater appears working
properly
B-3.15 Water jacket piping drip tight:
B-3.16 Diesel engine water hose hood condition:
B-3.17 Coolant antifreeze protection
B-3.18 Cooling line strainer
B-3.19 Solenoid valve operating correctly
B-3.20 Bearings and valves lubricated
Comments:
1.) Everything is in good condition.
Y N/A N

B-2.0 Annual Inspection of Electrical

Pump System:
B-2.6 Isolating switch closed-standby
emergency source
B-2.7 Normal phrase rotation pilot light “ON”: Y N/A N
B-2.8 Reverse phrase alarm pilot light “OFF”: B-4.0 Annual Inspection of Steam
Pump System:
B-2.9 Oil level in vertical motor sight glass B-4.1 Steam pressure gauge reading normal ________psi
in the normal range:
Comments: B-4.2 Record time required to reach running
speed: _______ min _____ sec
1.) All are in good condition. B-4.3 Weekly test conducted and results
Recorded:
Comments:

1.) All are in good condition

 (All “NO” answers to be fully explained)
Inspector’s Initia; RMT Owner/designated rep. initial_________________ Date:

Report of Inspection, Testing, & Maintenance of Fire Pumps . . . . continued

Y N/ N Y N/A N
A
C-1.0 Annual Test of Electric Pump C-2.0 Annual Test of Diesel Pump
Systems: System:
C-1.1 Electric pump weekly 10-min test run C-2.1 Weekly auto start/nun 30 min and results
results recorded (water flow not required) Recorded (water flow not required)
C-1.2 Time controller on first step for reduced C-2.2 Auto weekly test timer used for the
Voltage or reduce current starting: Starting procedure:
1 min _______sec
C-1.3 Record time pump runs after starting C-2.3 Time required for engine to crank
(for automatic stop controllers): ______min _______sec
______0 min 10 sec
C-1.4 Time required for motor to reach full speed C-2.4 Time required to reach running speed
______min 40 sec ______min _______sec
Comments: C-2.5 Observations while engine operating
1.) Good operating condition. Oil pressure: ______psi
Speed indicator ______rpm
Water temperature: ______° F
Oil temperature: ______° F
C-2.6 Pump operational without abnormalities
C-2.7 Heat exchanger cooling water flow normal
C-2.8 Alarm company notified of test run
C-2.9 Pump test run performed satisfactorily

Fire Pump Test

Pump Controller
Make: Make:
Type: Listed:
Rated capacity:
Rated pressure: Water Supply
Rated rpm: Source:

Power Electronic Characteristic

Type: ELECTRIC NONE
Supervision: NONE
Test Data:
Type of Test Static or Residual or Net pump Pump Pilot Dia. of No. of Flow at Opening Actual
(hydrant, suction discharge pressure speed pressure nozzle nozzle C=.90 coefficien Flow
drain or pressure pressure (psi) (rpm/ openings openings C=.97 t C= (gpm)
pump) (psi) (psi) amperes) flowed flowed (gpm)
Drain 105 psi 40 psi 145 psi 2800 100 psi 2 ½” 2 2/1” 0.90 0.90 110

Notes:
Remarks on test: Test was satisfactory._
______________________________________________________________________________________________________________

Signature and title of person making test:__ __ _Company name and address:_
Witness (owner or designated rep.)______________Date of examination: __________________________________
(All “NO” answers to be fully explained)
Inspector’s Initial: RMT Owner/designated rep. initial_________________ Date
 Mothly Inspection and Test of Fire Pump Components:
Conduct the Inspection and Test Tasks and Record Results as
Applicable to the Type of Pump System:

Y N/A N Y N/A N
D-1.0 Annual Inspection of System D-9.1 Automatic starts performed 10 times
Components:
D-1.1 Pump in service on inspection D-9.2 Automatic start function properly:
D-1.2 Pump identification no. ________ D-9.3 Automatic stop function properly:
D-1.3 Casing relief valve free of damage D-9.4 Automatic start psi: 40
D-1.4 Pressure relief valve free of damage D-9.5 Automatic stop psi: 90
D-1.5 ALL valves, fittings, pipe leak tight D-10.1 Manual start performed 10 times
D-1.6 Condensate drain trap clean: D-10.2 Manual start psi: 50
D-2.1 Fire pump controller power “ON” D-10.3 Manual stop function properly
D-2.2 Transfer switch normal pilot light “ON” D-10.4 Manual start psi: 50
D-3.1 Jockey pump operational D-10.5 Manual stop psi: 90
D-3.2 Jockey pump controller power “ON” D-11.1 Remote start function properly
D-3.3 Jockey pump controller set on “AUTO” D-11.2 Remote stop function properly
D-4.1 Fire pump shaft coupling appears D-11.3 Remote start psi: 40 PSI
properly
align
D-4.2 Packing glands appear properly adjusted D-11.4 Remote stop psi: 100 PSI
D-5.1 Weekly test run records available D-12.1 Timer indicates total run time: 4 min
D-5.2 Date of last pump run test D-12.2 timer reset and graph paper changed:
_____________
D-5.3 Pump peak load at 150% capacity D-12.3 Test data and flow charts completed:
_______ (Attach all water flow charts, electrical
power charts, performance curves, etc)
D-6.1 Test header control valve closed D-12.4 Fire pump electrical power readings
Recorded at each flow condition:
D-6.2 Test header in good condition D-12.5 Fire pump motor speed: 2800 rpm
D-6.3 Test header valves and caps in D-12.6 Fire pump discharge flow: 150 gpm
good condition
D-6.4 Test header valves handles in good D-13.1 Jockey pump operational
condition
D-6.5 Test header valve swivels rotation is D-13.2 Jockey pump appears properly aligned
nonbinding
D-7.1 By-pass control valves open D-13.3 Jockey pump valves open:
D-7.2 Control valves sealed/not tampered D-13.4 Jockey pump “turn-on”: 50 psi
D-7.3 Control valves locked/tampered D-13.5 Jockey pump “ turn-off”: _______psi
D-7.4 Control valves properly tagged and D-20.0 Comments:
identified
D-7.5 Flow meter control valves closed:
D-8.1 Relief valve and cone operational:
D-8.2 Relief valve pressure appears properly
adjusted:
D-8.3 Suction gauge while flowing psi: 100
D-8.4 Fire pump operating psi: 90
D-8.5 Discharge gauge flowing psi: 100

Note: Pump performance curve should be plotted on page 5 of 5.

 (All “NO” answers to be fully explained)
Inspector’s Initial : RMT Owner/designated rep. initial_________________ Date:
B. Testing C. Maintenance
The following tests are to be performed at the noted intervals. Report any 1. Regular Maintenance items
failures on Part III of this form. A. Item found missing or in disrepair during
1. Quarterly Tests
inspection or testing repaired or replaced? Yes No N/A
A. Mechanical waterflow alarm devices passed tests by opening the inspector’s
test connection or bypass connection B. Air leaks in dry-pipe systems resulting in air
with alarm actuating and flow observed? pressure loss more than 10 psi/week repaired?Yes No N/A
Yes No N/A
B. Post indicator valves opened until spring or torsion is felt C. Dry system being maintained in dry condition?Yes No N/A
in the rod, then closed back one quarter turn? Yes No N/A D. if any of the following were discovered, was an obstruction
C. Priming water level (dry-pipe) passed test? Yes No N/A investigation conducted? Yes No N/A
D. Low air pressure signal (dry-pipe) passed test? Yes No N/A Explain reason(s) and obstruction investigation findings in part III
E. Quick opening device passed test? Yes No N/A 1. Defective intake screen for pumps taking suction from open sources.
F. Main Drain Test for system downstream of backflow or pressure
2. Obstructive material discharged during waterflow test.
reducing valve (automatic water supply) : Yes No N/A
1. Record static pressure ______ psi and residual pressure ________ psi 3. Foreign material found in dry-pipe valves, check valves or pumps.
2. Was flow observed? 4. Heavy discoloration of water during drain test or plugging of
Yes No N/A inspector’s test connection.
3. Are results comparable to previous test ?
2. Semiannual Test (in addition to above items)
Yes No N/A 5. Plugging found in piping dismantled during alterations.
A. Electrical waterflow alarm devices passed tests by opening 6. Failure to flush yard piping or surrounding public mains following
inspector’s test connection or bypass connection new installation or repairs.
with alarm actuating and flow observed? Yes No N/A 7. Record of broken main in the vicinity.
B. Valve supervisory devices indicate movement? Yes No N/A 8. Abnormally frequent false tripping of dry-pipe valves.
3. Annual Tests (in addition to above items)
A. System Main Drain Test (automatic water supply) 9.system is returned to service after an extended period out of service
1. Record static pressure ______ psi and residual pressure ________ psi (greater than one year)
2. Was flow observed? Yes No N/A 10. There is reason to believe the system contains sodium silicate or
3. Are results comparable to previous tests? Yes No N/A its derivatives.
B. Specific gravity of antifreeze correct? Yes No N/A E. If conditions were found that required
C. All control valves operated through full range flushing, was flushing of system conducted? Yes No N/A
and returned to normal position? Yes No N/A 2. Annual Maintenance items (in addition to above items)
D. Low temperature alarms in dry-pipe enclosures
A. Operating stem of all OS&Y valves lubricated.
Yes No N/A
passed test? Yes No N/A
E. Dry-pipe valve partial flow trip test B. Hose reracked or rerolled so folds do not occurred in same
1. Record initial air pressure _______ psi and water pressure _______ psi position? Yes No N/A
2. Record tripping air pressure ________ psi and time _______ psi C. Interior of dry-pipe valves cleaned? Yes No N/A
3. Above result comparable to previous tests? Yes No N/A D. Low points drained in dry systems prior to
F. Automatic air maintenance device on dry-pipe onset of freezing weather? Yes No N/A
system passed test Yes No N/A
G. Backflow devices passed backflow test? Yes No N/A Part III – Comments (Any “No” answers, test failure or other problems
H. Backflow devices passed full flow test? Yes No N/A found with the standpipe and hose systems must be explained here)
I . Pressure reducing valves passed partial
flow test? Yes No N/A
4. Third Year Test (in addition to above items) _____________________________________________________________
A. Dry-pipe Valve Full Flow Trip Test: _____________________________________________________________
1. Record initial air pressure ______ psi and water pressure ______ psi _____________________________________________________________
2. Record tripping air pressure ______ psi and tripping time _______ psi _____________________________________________________________
3. Was water delivered to inspectors test _____________________________________________________________
connection? Yes No N/A _____________________________________________________________
B. Is hose less than five years old? Yes No N/A _____________________________________________________________
If “ no,” has hose been tested within three years? Yes No N/A
if “ no,” test hose now and every three years. _____________________________________________________________
5. Fifth Year Test _____________________________________________________________
A. Gauges tested against calibrated one or replaced? Yes No N/A _____________________________________________________________
B. Automatic standpipe system tested at required flows: _____________________________________________________________
1. Record static pressure 100 psi and residual pressure _______ psi _____________________________________________________________
2. Record total flow ________ gpm _____________________________________________________________
3. Above flows and pressures acceptable? Yes No N/A _____________________________________________________________
C. Manual system not a part of a sprinkler/standpipe
_____________________________________________________________
system passed hydrostatic test? Yes No N/A
D. All hose connection and hose rack assembly pressure _____________________________________________________________
reducing and valves passed full flow test? Yes No N/A _____________________________________________________________
_____________________________________________________________

Part IV - inspectors Information

Inspector:_______________________________________
Company:_________________________________________
Company Address: _________________________________

I state that the information on this form is correct at the time an

place of my inspection and that all equipment tested at this time wa
left in operational condition upon completion of this inspectio
 except as note in Part III above.

Signature of Inspector:__________________Date:__
License or Certification Number (if applicable)_:
PCAB # : 37521____

Form for Inspection, Testing and Maintenance of Standpipe and Hose Systems

Information on this form covers the minimum requirement of NFPA 25-2006 for standpipe and hose systems.
Where the standpipe system includes a fire pump and water tank, an additional form must be completed for inspection testing and
maintenance of the pump tank. Forms are available for fire sprinkler systems, private fire service mains, water spray fixed system and
foam-water sprinkler systems. More frequent inspection, testing and maintenance may be necessary depending on the condition of the
occupancy and the water supply.
Owner:FATIMA UNIVERSITY MEDICAL CENTER Owner’s Phone Number:_292-XXXX
Owner’s Address:_MAC ARTHUR HIGHWAY, VALENZUELA CITY
Property Being Evaluated: AUTOMATIC FIRE SPRINKLER SYSTEM
Property Address: MAC ARTHUR HIGHWAY, VALENZUELA CITY
Date of Work:_JAN. 8, 2016 All responses refer to the current work (inspection, testing and maintenance) performed on this date.
This work is (check one) Monthly Quarterly Semiannual Annual
Note: 1) 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.
2) Inspection, Testing and Maintenance are to be perform with water supplies (including fire pumps) in service,
unless impairment procedures of Chapter II of NFPA 25 are followed.

Part I – Owner’s Section B. Test

A. Is the fire pump in service? Ye No N/A 1. Weekly Test Items

s
B. Has the fire pump remained in Ye No N/A A. Electrical Motor-
service s Driven
since the last inspection? Pumps
C. Was the system of which the fire Ye No N/A 1. Pump started Ye No N/A
pump s automatically? s
is a part free from actuation of Record starting pressure
devices 100 psi
2. Pump run for at least 10 Ye No N/A
or alarm since the last operation?
minutes? s
Record suction_____ and
discharged _____ pressure
while running
Note to owner: Periodic tests of transfer switches and emergency
generators
are to be performed in accordance with NFPA 110 by a qualified
3. Pump packing gland Ye No N/A
electrical contractor
showing slight s
discharged?
__________________ ______________________ Adjust if necessary?
Owner of representative (print name) Signature and Date 4. Free from unusual noises Ye No N/A
or s
vibration?
Part II – Inspector’s Section 5. Packing boxes, bearings Ye No N/A
and pump casing free s
from
overheating?
A. Inspections – All to be performed weekly 6. Record time for motor to
accelerate to full speed
_____
1. Pump house/room proper Ye No N/A 7. For reduced voltage or
temperature s reduced current starting
at least 70º F for others)? record time controller on
first step _________
2. Ventilating louvers free to Ye No N/A 8. For automatic stop
operate? s controllers, record time
pump
runs after starting
_______
3. Suction, discharge and bypass 9. All times and pressure in Ye No N/A
valves Part A acceptable? s
open?
4. Piping free from leaks? Ye No N/A B. Diesel Engine-Driven
s Pumps
5. Suction and system pressure Ye No N/A 1. Pump started Ye No N/A
gauges s automatically? s
normal? Record starting pressure
_______psi
6. Suction reservoir, if provided full? Ye No N/A 2. Pump run for at least 30 Ye No N/A
s minutes? s
Record suction _____ and
discharge ______
pressure
while running.
7. Electric Motor Driven 3. Pump packing gland Ye No N/A
showing slight discharge? s
a. Controller indicating power en Ye No N/A Adjust if necessary.
transfer switch indicating normal s
situation and isolation switch
closed?
b. Reverse phrase alarm indicator Ye No N/A 4. Free from unusual noises Ye No N/A
off or on normal phase rotation s or s
indicator on? vibrations?

c. Oil level in vertical motor sight Ye No N/A 5. Packing boxes bearings Ye No N/A
normal? s and s
pump causing free from
overheating?
8. Diesel Engine Driven Pumps 6. Record time for engine to
crank _______
a. Fuel tank at least two thirds full? Ye No N/A 7. Record time for engine to
s reach running speed
_______
b. Controller selector switch in Auto Ye No N/A 8. Engine oil pressure Ye No N/A
position? s gauge, s
speed indicator water and
oil temperature indicators
all
reading normal?
c. Battery voltage and charger Ye No N/A 9. Cooling water flowing Ye No N/A
readings s from s
normal heat exchanger?
d. Battery indicators on or failure Ye No N/A 10. All times and pressure in Ye No N/A
indicators off? s Part B acceptable? s
e. All alarm indicator off? Ye No N/A C. Steam Turbine-driven
s Pumps
f. Record engine running time meter Ye No N/A 1. Record pump starting
reading appropriately higher than s pressure ____, suction
previous reading? ____
g. Oil level in right angle gear driven Ye No N/A and discharge _____
while
normal? s
running
h. Crankcase oil level normal? Ye No N/A 2. Pump packing gland Ye No N/A
s showing slight discharge? s
Adjust if necessary.
i. Cooling water level normal? Ye No N/A 3. Free from unusual noises Ye No N/A
s or s
vibrations?
j. Electrolytes level in batteries Ye No N/A 4. Packing boxes, bearings Ye No N/A
normal? s and pump causing free s
from
overheating?
k. Battery terminals free from Ye No N/A 5. Record steam pressure
corrosion? s gauge reading _________
l. Water jacket heater operating? Ye No N/A 6. Record time for turbine to
s reach running speed
______
9. Steam pressure gauge for steam Ye No N/A 7. All times and pressures in Ye No N/A
drive pump reading normal? s Part C acceptable? s
10. Circulation relief valve flowing Ye No N/A
water while pump churns? s
11. Pressure relief valves operating Ye No N/A
with proper pressure downstream s
while
pump is operational?
2. Annual Tests 2. Monthly Maintenance Items
Annual pump test was run using the following method: (check one) A. Isolation switch and circuit breaker Yes No N/A
Method A. Discharge of flow through hose streams. exercised?
Flow readings taken at each hose stream. B. Battery case clean, dry and free of corrosion and battery’s specific
gravity or state of charge passed test? Yes No N/A
Method B. Discharge through by-pass flow meter to drain or C. Charger and charge rate passed visual inspection
suction reservoir. Flow readings taken by flow meter. and battery charged being equalized? Yes No N/A
Method C. Discharge through by-pass flow meter directly D. Circuit breakers appear clean? Yes No N/A
3. Quarterly Maintenance Items
returned to pump suction. Flow readings taken by flow meter
A. Cleaned strainer, filter or dirt leg in
Pump Test Results diesel fuel sytem Yes No N/A
B. Cleaned or replace crank case breather
in lubrication system? Yes No N/A
No Flow Rated Flow Peak Flow
C. Cleaned water strainer in coolant system? Yes No N/A
Suction D. Insulation acceptable and fire hazards
Pressure eliminated from exhaust system? Yes No N/A
Discharge E. Battery terminals clean and tight? Yes No N/A
Pressure F. Electrical system free or wire chafing? Yes No N/A
4. Semi Annual Maintenance Items
Flow N/A A. Manual starting means electrical systems operated
and boxes, panels and cabinet cleaned? Yes No N/A
Electric Voltage
N/A B. Antifreeze tested in coolant system? Yes No N/A
and Current C. Flexible exhaust section acceptable? Yes No N/A
Pump D. Alarms operated on electrical portion of
Speed diesel engine systems? Yes No N/A
5. Annual Maintenance Item:
A. Are the value in the above table acceptable Yes No N/A A. Changed pump bearing lubrication? Yes No N/A
B. No-flow (churn) test run for 30 min? B. Shaft end play acceptable? Yes No N/A
Yes No N/A C. Transmission coupling right angel gear drive
C. Circulation relief valve and pressure relief valve
and mechanical moving parts lubricated? Yes No N/A
operated properly during all flow tests? Yes No N/A Yes No N/A
D. Circuit breakers passed trip test?
D. No alarm indicator or other visible E. Emergency manual starting means operated
abnormalities observed during no flow test Yes No N/A without power? Yes No N/A
E. Suction screens cleaned after flow? Yes No N/A F. Electrical connection secure? Yes No N/A
F. Low suction throttling device test G. Pressure switched setting calibrated? Yes No N/A
1. Low suction pressure simulated? Yes No N/A H. Motor bearing greased? Yes No N/A
Free from abnormalities throttling action Yes No N/A I. Fuel tank free of water and foreign material, tank vents and
2. Free from abnormalities in return to full flow overflow pipes free of obstruction, fuel piping acceptable and
G. Automatic Transfer Switch Test oil and filters changed in diesel system? Yes No N/A
J. Antifreeze changed in coolant system? Yes No N/A
1. Power failure simulated during peak flow? Yes No N/A
Connection made to alternate power source?
K. Heater exchanger cleaned out? Yes No N/A
Yes No N/A
2.After termination of simulated power failure did motor L. Duck work and louvers (combustion air Yes No N/A
reconnect to the normal power source? acceptable?
Yes No N/A
H. All alarm condition simulated? M. Exhaust system free of back pressure? Yes No N/A
Yes No N/A
All alarms operated? N. Exhaust system hanger and support
Yes No N/A acceptable?
C. Maintenance Yes No N/A
A maintenance schedule must be established in accordance with the O. Control and power wiring tight? Yes No N/A
manufacture’s instructions. In the absence of such a schedule, the
Part III – Comments (Any “No” answers, test failure or other problems
following must be used:
found with the standpipe and hose systems must be explained here)
1. Weekly Maintenance Items for Diesel Engine Systems:
A. Fuel tank level, tank float switch and ____________________________________________________________
solenoid valve operation acceptable? Yes No N/A ____________________________________________________________
B. Diesel fuel system free of water? Yes No N/A ____________________________________________________________
C. Flexible hoses and connectors in fuel and ____________________________________________________________
coolant systems acceptable? Yes No N/A ____________________________________________________________
D. Oil level and lube oil heater acceptable? ____________________________________________________________
E. Coolant level acceptable? Yes No N/A
F. Water pump for coolant system operating? Part IV - inspectors Information
Yes No N/A Inspector:_________________________________________
G. Jacket water heater for coolant system
acceptable? Yes No N/A Company:_________________________________________
H. Exhaust system free of leakage? Company Address: _________________________________
Yes No N/A
I. Drain condensate trap on exhaust system
operational? Yes No N/A I state that the information on this form is correct at the time and
J. Electrolyte level in batteries acceptable? Yes No N/A place of my inspection and that all equipment tested at this time was
K. Connections to electrical system left in operational condition upon completion of this inspection
acceptable? Yes No N/A except as note in Part III above.
Signature of Inspector:__________________Date:________
License or Certification Number (if applicable)
PCAB # : 37521___________
3. Tests ( in addition to previous items) Part III – Comments (Any “NO” answers test, failures or
A. Main drain test: other problems found with the sprinkler system must be
1. Record static Pressure____ and and Residual explained here. Also, note here any products notices on the
Pressure____psi. systems that have been the subject of a recall or a
replacement program)
2. Was flow observed? Ye No N/A _________________________________________________
s _________________________________________________
3. Are results compatible to Ye No N/A _________________________________________________
previous test? s _________________________________________________
B. Are all sprinklers derived 1920 Ye No N/A _________________________________________________
or later? s _________________________________________________
C. Fast response sprinklers 30 or Ye No N/A _________________________________________________
more years old replaced or s _________________________________________________
successfully sample tested _________________________________________________
within last 10 years? _________________________________________________
D. Standard response sprinkler 50 Ye No N/A _________________________________________________
or more years old replace or s _________________________________________________
successfully sample tested _________________________________________________
within last 10 years? _________________________________________________
E. Standard response sprinkler 75 Ye No N/A _________________________________________________
or more years old replace or s _________________________________________________
successfully sample tested _________________________________________________
within last 5 years? _________________________________________________
F. Dry-type sprinklers replaced or Ye No N/A _________________________________________________
successfully sampled tested s _________________________________________________
within 10 years? _________________________________________________
G. Specific gravity of antifreeze Ye No N/A _________________________________________________
correct? s _________________________________________________
H. All control valve separated Ye No N/A _________________________________________________
through full range and returned s _________________________________________________
to normal position? _________________________________________________
I. Backflow devices passed Ye No N/A _________________________________________________
backflow test? s _________________________________________________
J. Backflow devices passed Ye No N/A _________________________________________________
full flow test? s _________________________________________________
K. Pressure reducing valves passed Ye No N/A _________________________________________________
partial flow test? s _________________________________________________
4. Test to be done every third year: Ye No N/A _________________________________________________
Hose (more than 5 years old) s _________________________________________________
corrected to the system has _________________________________________________
been services tested in _________________________________________________
accordance with NFPA 1962. _________________________________________________
Water discharge and water flow _________________________________________________
alarms operated? _________________________________________________
5. Test to be done every fifth year. _________________________________________________
A. Sprinkler rated above high Ye No N/A _________________________________________________
Temperature tested? s _________________________________________________
B. Gages checked by calibrated Ye No N/A _________________________________________________
gage or replaced? s _________________________________________________
C. Pressure reducing valves passed Ye No N/A _________________________________________________
full flow test. s _________________________________________________
C. Maintenance Ye No N/A _________________________________________________
s _________________________________________________
1. Regular Maintenance Items: _________________________________________________
A. If sprinklers have been change Ye No N/A _________________________________________________
have been replaced were they s _________________________________________________
proper replacements? _________________________________________________
B. Use hose was cleaned, drained Ye No N/A _________________________________________________
and dried before being place back s _________________________________________________
in service? Hose exposed to _________________________________________________
hazardous materials was disposed _________________________________________________
 of or decontaminated in an _________________________________________________
approved manner? _________________________________________________
C. Systems normally filled with fresh Ye No N/A _________________________________________________
water drained and refilled twice if s _________________________________________________
raw water got in to the system? _________________________________________________
D. If any of the following was Ye No N/A _________________________________________________
discovered, was an obstruction s _________________________________________________
investigation conducted? _________________________________________________
Explain reason(s) and obstruction Ye No N/A _________________________________________________
investigation findings in Part III. s _________________________________________________
1. Defective intake screen of pump
with suction from open sources.
2. Obstruction material discharged Part IV: Inspector’s Information:
during water flow test? Inspector: RAUL TUSCANO
3. Foreign materials found in dry- Company: NAPERVILLE BUILDERS
pipe valves, check valves or Company Address: 102 RD. 1, PROJ. 6, QUEZON CITY
pumps.
4. Foreign material in water during I state that the information on this form is correct at the time
drained test or plugging of and place of my inspection and that all equipment tested at
inspector’s test connection. this time was left in operational condition upon completion
5. Plugging or pipe or sprinklers of this inspection except as note in Part III above.
found during activation of
alternation.
6. Failure to flush yard piping or Signature of Inspector: RMT Date
surrounding public mains License or Certification Number (if applicable): 37521
following new installation or
repairs.
7. Record of broken mains in the
vicinity.
8. Abnormally frequent false-tripping
of dry-pipe valves.
9. System in returned to service after
an extended period out of service
(greater than one year)
10. There is reason to believe the
system contains sodium silicate or
its derivatives or highly corrosive
in fluxes in copper pipe systems.
E. If condition found that required Ye No N/A
flushing, was flushing of system s
conducted?
2. Annual Maintenance Items (in
addition to previous items)
A. Operating stem of all OS&Y Ye No N/A
valves lubricated, completely s
closed and reopened?
B. Sprinkles and spray nozzles Ye No N/A
protecting commercial cooking s
equipment and ventilating
systems except for bulb-type
which show no signs of grease
buildup.
Form for Inspection, Testing and Maintenance of Standpipe and Hose Systems

Information on this form covers the minimum requirement of NFPA 25-2006 for standpipe and hose
systems.
Where the standpipe system includes a fire pump and water tank, an additional form must be completed for
inspection testing and maintenance of the pump tank. Forms are available for fire sprinkler systems, private
fire service mains, water spray fixed system and foam-water sprinkler systems. More frequent inspection,
testing and maintenance may be necessary depending on the condition of the occupancy and the water
supply.
Owner: Owner’s Phone Number:292-XXXX
Owner’s Address
Property Being Evaluated: Property Address:_ Date of Work:_ All responses refer to the current work
(inspection, testing and maintenance) performed on this date.
This work is (check one) Monthly Quarterly Semiannual Annual Third Year Fifth Year
Note: 1) 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.
2) Inspection, Testing and Maintenance are to be perform with water supplies (including fire pumps) in
service,
unless impairment procedures of Chapter II of NFPA 25 are followed.
Part I – Owner’s Section 4. Quarterly Inspection Items (in additional to
above items)
A. Is the building occupied? Y N A. Hose Valve Outlet:
es o
B. Has the occupancy and Y N Valve not leaking and Y N N/
classification and hazard es o no visible obstructions es o A
of with caps, hose
contents remained the connections, valve
same since handle, cap gasket,
the last inspection? restricting devices in
place, undamaged and
in good condition?
C. Are all fire system Y N B. Visible pipe and Y N N/
protection es o supports in good es o A
systems in service? condition?
D. Has the system remained Y N C. Alarm devices free Y N N/
in es o from physical es o A
service without damages?
modification since
the last inspection?
E. Was the system free of Y N D. Fire Department Y N N/
actuation es o Connections. es o A
of devices or alarms since Visible, accessible,
the last couplings and swivels
inspection? not damaged and
rotate smooth plugs or
caps in place in
undamaged, gaskets in
place and in good
condition,
identification sign(s)
in place, check valve
not leaking, clapper is
in place and operating
properly and
automatic drain valve
in place and operating
properly?
(If plugs or caps are
not in place inspect
interior for
 obstruction)
_______________________ 01/2016 5. Annual Inspection
_______ Signature and Items (in addition to
Owner or representative Date above items)
(print name)
A. Hose free from Y N N/
mildew, cuts and es o A
deterioration,
couplings of
compatible threads
and undamaged
gaskets in place and
good condition, and
hose connected?
Part II – Inspector’s B. Hose Nozzles.
Section
A. Inspections 1. Nozzles and gaskets Y N N/
in place and good es o A
condition?
1. Daily and Weekly 2. No visible Y N N/
Inspection Items obstructions? es o A
A. Enclosure around dry-pipe Y N N/A 3. Nozzles operate Y N N/A
valves es o smoothly? es o
(without low temperature
alarms) maintaining a
minimum of 40 °F ?
B. Relief port on reduced Y N N/A C. Hose Storage Y N N/A
pressure es o Devices. es o
backflow prevention 1. Hose properly
assemblies not continuously racked or rolled?
discharged.
C. Gauges on dry system Y N N/A 2. Nozzle clips and Y N N/A
(now low pressure alarm in es o place and nozzle es o
good condition showing contained?
normal air and water
pressure?
D. Sealed control valves and Y N N/A 3. Undamaged, Y N N/A
valves backflow assemblies es o unobstructed and es o
in normal (open or closed) operable?
position accessible with seals
and place with free from 4. Will racks swing Y N N/A
external leaks, and provided out of cabinet at least es o
with appropriate 90°?
identification. ? D. Storage Cabinet:

2. Monthly Inspection 1. Cabinet have no Y N N/A

Items corroded or damaged es o
parts are easy to fully
open, and are
accessible and
identified?
A. Dry -Pipe Valves Y N N/A 2. Door glazing in Y N N/A
Enclosure around valves es o good condition? es o
(with low temperature 3. Locks functioning Y N N/A
alarms) maintaining a in break-glass type es o
minimum with of 40 °F, free cabinets?
from physical damages, trim
valves in appropriate (open 4. All parts, valves Y N N/A
or closed) position with no hoses and fire es o
leakage from intermediate extinguishers
chamber? accessible?

E. Adequate heat Y N N/A

available to areas es o
where wet pipe is
located?

(Must be done before

cold weather)

B. Pressure Reducing Valves F. Interior of dry-pipe Y N N/

(Hose Connection) valves (which must be es o A
open passed internal
inspection?
1. Hand wheels in place and Y N N/A 6. Fifth Year Y N N/
good condition? es o Inspection Items (in es o A
addition to previous
items)
2. Hose threads in good Y N N/A A. Interior of dry-pipe Y N N/
condition? es o valves, (which can be es o A
reset without opening)
passed internal
inspection?
3. Valves not leaking? Y N N/A B. Alarms valves and Y N N/
es o their associated es o A
strainers, filters and
restriction orifices
passed internal
inspection?
4. Reducers and caps in place Y N N/A C. Check valves Y N N/
& in good condition? es o internally inspected es o A
and all parts operate
properly, move freely
and are in good
condition?
C. Pressure Reducing Valves (Hose D. Strainers, filters, Y N N/
Rack) restricted orifices and es o A
diaphragm chambers
on dry-pipe valve
passed internal
inspection?
1. Hand wheels in place and Y N N/A Y N N/
good condition? es o es o A

3. Valves not leaking? Y N N/A

es o
D. Gauge (on dry system Y N N/A
with low pressure or on wet es o
system) in good condition
and showing normal air and
water pressure?
E. Control Valves and Y N N/A
Valves on Back-flow es o
Assemblies (with locks or
electric supervision) in
normal (open or closed)
position with locks or
supervision in place,
accessible, free from external
leaks, provided with
appropriate wrenches and
provided with appropriate
idenfication?
F. Alarms devices free form Y N N/A
physical damages? es o
G. Alarm Valves free from Y N N/A
physical damage, valves in es o
correct (open or closed)
position no leakage from
retard chamber or drains,
gauges indicating normal
water pressure?
Form for Inspection, Testing and Maintenance of Wet Pipe Fire Sprinkler Systems

Information on this form covers the minimum requirements of NFPA 25-2002 for fire sprinkler systems connected to distribution system without
supplemental tanks of fire pumps. Separate forms are available to inspect, test and maintain fire pumps, water tanks and other fire protection systems.
More frequent inspection, testing and maintenance may be necessary depending of the occupancy and the water supply.

Owner: Owner’s Phone Number : 292-0000

Owner’s Address:
Property Being Evaluated:
Property Address
Date of Work:JAN. 8, 2016 All responses refer to the current work (inspection, testing and maintenance) performed on this date

This work is (check one) Monthly Quarterly Annual Third Year Fifth Year

Note: 1) All questions are to be answered Yes, No, or Not Applicable. All No answers are to be explained in part III of this form.
2) Inspection, Testing and Maintenance are to be performed with water supplies (Including fire pumps) in service, unless the impairment .
procedures of Chapter 11 of NFPA 25 are followed

Part I – Owner’s Section 6. Annual Inspection Items (in addition to above items)
A. Is the building occupied? YES NO N/A A. Proper number and type of spare sprinklers?
B. Has the occupancy classification and hazard of YES NO N/A
contents remained the same since the last inspection? YES NO N/A B. Visible Sprinkler:
C. Are all fire protection system in service? 1. Free of corrosion and physical damage? YES NO N/A
D. Has the system remained in service without 2. Free of obstructions to spray patterns? YES NO N/A
modification since the last inspection? YES NO N/A 3. Free of foreign materials including paint? YES NO N/A
E. Was the system free of actuation of devices 4 Liquid in all glass bulb sprinklers? YES NO N/A
or alarms since the last inspection YES NO N/A C. Visible pipe:
1. In good condition/no external corrosion? YES NO N/A
Owner or representative name (print name) 2. No mechanical damage and leaks? YES NO N/A
Part II – Inspector ‘s Section 3. Properly align and no external load? YES NO N/A
A. Inspector D. Visible pipe hangers and seismic braces
1. Daily and Weekly items Not damaged or loose? YES NO N/A
A. Control valves supervised with seal in E. Hose, hose coupling and nozzles on sprinkler system passed
correct (Open or Closed) position? YES NO N/A Inspection in advantage with NFPA 1962? YES NO N/A
B. Backflow Preventers F. Adequate heat in areas with wet piping? YES NO N/A
1. Valve is correct (open or closed) position? YES NO N/A G Has an internal inspection of the pipe been performed by
2. Sealed, locked or supervised & accessible? YES NO N/A removing the flushing connection and one sprinkler near the end
3. Relief port on RPZ device not discharging? YES NO N/A of a branch line within the last 5 years? YES NO N/A
4. Monthly Inspection items(in addition to above items) (If the answer was “No” conduct on internal inspection)
A. Control valves with locks or electrical supervision 8. Fifth year inspection item (in addiction to above item)
In correct (open or closed) position? YES NO N/A A. Alarm valve and their associated and all parts operated properly
B. Sprinkler wrench with spare sprinkler? YES NO N/A Move freely and are in good condition? YES NO N/A
C. Gauges on wet-pipe system in good condition B. Check valves internally inspected and all parts operate properly
And showing normal water supply pressure? YES NO N/A move freely and are in good condition? YES NO N/A
B. Testing
D. Alarm Valves : The following tests are to be performed at the noted intervals.
Gauges show normal supply water pressure, free from physical Report any failures on Part III of this form.
damage, valves in correct (open or closed) position and no leakage 1. Quarterly Tests
from retarding chamber or drains? YES NO N/A A. Mechanical waterflow alarm devices passed tests by opening
5. Quarterly inspection items (in addition to above items) the inspector’s test connection or bypass connection with alarms
A. Pressure Reducing Valves: In open position, not leaking, maintain actuating and flow observed? YES NO N/A
downstream pressure per design criteria, and in good condition with handwheels B. Post indicating valves opened until spring or torsion is felt in the
not broken? YES NO N/A rod, then closed back one-quarter turn? YES NO N/A
B. Hydraulic nameplate (calculate systems) C. Main drain test for system downstream of backflow or pressure
Securely attached to riser and legible? YES NO N/A reducing valve:
C. Fire Department Connections: 1. Record Static Pressure ___ psi and Residual pressure ____ psi
Visible, accessible, couplings and swivels not damaged and rotate 2. Was flow observed? YES NO N/A
smoothly, plugs or caps in place and undamaged, gaskets in place and in 3. Are result comparable to previous test? YES NO N/A
good condition, identification sign(s) in place, check valve is not leaking 2. Semiannual test (in addition to previous items)
clapper is in place and operating properly and automatic drain valve in place A. Valve supervisory switches indicate
and operating properly? YES NO N/A movement? YES NO N/A
(If plugs or caps are not in place, inspect interior for the obstructions.) B. Electrical water flow alarm devices passed tests by opening the
D. Alarm devices free from physical damage? YES NO N/A inspector’s test connection or bypass connection with alarms
actuating and flow observed? YES NO N/A
Form for Inspection, Testing and Maintenance of Standpipe and Hose Systems

Information on this form covers the minimum requirement of NFPA 25-2006 for standpipe and hose systems.
Where the standpipe system includes a fire pump and water tank, an additional form must be completed for inspection testing and
maintenance of the pump tank. Forms are available for fire sprinkler systems, private fire service mains, water spray fixed system
and foam-water sprinkler systems. More frequent inspection, testing and maintenance may be necessary depending on the condition
of the occupancy and the water supply.
Owner: Owner’s Phone Number:292-XXXX
Owner’s Address
Property Being Evaluated:
Property Address: Date of Work: JANUARY 6, 2016
_All responses refer to the current work (inspection, testing and maintenance) performed on this date.
This work is (check one) Monthly Quarterly Semiannual Annual Third Year Fifth Year
Note: 1) 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.
2) Inspection, Testing and Maintenance are to be perform with water supplies (including fire pumps) in service,
unless impairment procedures of Chapter II of NFPA 25 are followed.

Part I – Owner’s Section B. Testing

A. Is the water storage tank in Ye No 1. Monthly Tests
service? s
B. Has the tank remained in Ye No a. Low water temperature Ye N N/A
services since the last inspection? s alarms passed test? s o
C. Was the system (of which the Ye No b. High temperature limit Ye N N/A
tank is a part) free from actuation s switches on tank heating s o
of devices or alarms since the last system passed test? Only
inspection? test when heating system is
on
2.Quarterly Test ( in
__________________________________ _________01/08/2016 addition to above items)
Owner or representative (printed name) Signature and Date
Part II – Inspector’s Section a. High water level alarm Ye N N/A
passed test? s o
A. Inspection b. Low water level alarm Ye N N/A
passed test? s o
1. Daily items during cold weather Ye No N/A 3. Semiannual Test (in Ye N N/A
where tank is subject to freezing s addition to above items) s o
which can be weekly if tank is Valve supervisory devices
electronically supervised indicates movements?
a. Heating system operational? Ye No N/A 4. Annual Test – Before Ye N N/A
s Freezing Weather (in s o
addition to above)
Tank heating system in
proper working order?
b. Record water temperature Ye No N/A 5.Interior tests to be
___________Acceptable? s performed every third or
fifth year with the internal
inspection of Part II A 7 of
this form
2. Weekly Inspection Item (in a. Tank coating passed Ye N N/A
addition to above items) adhesion coating thickness, s o
and wet sponge test?
Sealed valves in proper (open or Ye No N/A b. Tank wall and bottoms Ye N N/A
closed position) s passed ultrasonic test if s o
evidence of pitting or
corrosion?
3. Monthly Inspection Items (in c. Flat bottom tank passed Ye N N/A
addition to above items) vacuum box test? s o
a. Embankment-Supported Ye No N/A 6. Every Fifth Year Test
Rubberized- Fabric tanks free from s
erosion along exterior sides?
b. Locked and supervised valves in Ye No N/A a. level indicators accurate Ye N N/A
proper (open or closed) position? s and free to move? s o
c. Gages in good condition, Ye No N/A b. Gages compared to Ye N N/A
showing normal pressure? s calibrated gage or s o
replaced?
4. Monthly items which can be C. Maintenance
done quarterly when tank is
electronically supervised (in
addition to above items)
a. Water level in condition correct? Ye No N/A 1.Semiannual Maintenance Ye N N/A
s Sediment drained or s o
flushed from the tank?

b. Air pressure in pressure tank Ye No N/A 2. Annual Maintenance (in Ye N N/A

correct? s addition to above items) s o
Cathodic protection
maintained in accordance
with manufacturer’s
instructions all the tank
drains fully opened then
closed, and tank vents
cleaned?
5. Quarterly Inspection Items (in
addition to above items)
a. Exterior of tank, support Ye No N/A
structure, foundation condition of s
water in tank, catwalks and ladders
strong and free from obvious
damage?
b. Area surrounding tank free from Ye No N/A
combustibles, materials which s
could accelerate corrosion and ice?
c. Tank vents clean Ye No N/A
s
6. Annual Inspection Items (in
addition to above items)

a. Exterior coated and insulated Ye No N/A

surfaces of tank and supporting s
structure free from degradation?
b. Expansion joints not leaking or Ye No N/A
cracking? s
c. Hoops and grills on wooden Ye No N/A
tanks in acceptable condition? s
7. Interior Inspection to be Ye No N/A Part IV: Inspector’s Information:
performed once every three years s Inspector:
on pressure tanks and steel tanks Company:
without corrosion protection and Company Address: 1
once every five years on all other
tanks I state that the information on this form is correct at the
Interior coating in good condition, time and place of my inspection and that all equipment
center columns of tubular design tested at this time was left in operational condition
not holding water, center columns upon completion of this inspection except as note in
not permanently attached to the Part III above.
floor, tanks on ring type foundation
with sand in the middle have no
voids beneath the floor, heating
system components and piping in Signature of Inspector: _Date:
good condition, and anti-vortex License or Certification Number (if applicable):
plates in good condition?