BACKFLOW PREVENTION ASSEMBLY TEST REPORT

NAME OF PREMISE       Commercial Residential

SERVICE ADDRESS                  

CUSTOMER PRINTED NAME       PHONE       FAX      

LOCATION OF ASSEMBLY      

TYPE OF HAZARD ISOLATED       DCVA RPBA OTHER

NEW INSTALLATION EXISTING REPLACEMENT LINE PRESSURE:       PSI

MAKE OF ASSEMBLY       MODEL       SERIAL #       SIZE ”      

AIR GAP INSPECTION: Required minimum air gap separation provided? Yes No PROPER INSTALATION? YES NO

INITIAL TEST

PASSED

FAILED

DCVA / RPBACHECK VALVE #1

DCVA / RPBACHECK VALVE #2

RPBA PVBA / SVBA

LEAKED CLOSED TIGHT

      PSID

LEAKED CLOSED TIGHT

      PSID

OPENED AT       PSID AIR INLETOPENED AT       PSID

#1 CHECK       PSID

AIRGAP OK?       DID NOT OPEN

NEW PARTSAND

REPAIRS

CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVEHELD AT       PSID                 

                  LEAKED

                  CLEANED

                  REPAIRED

TEST AFTERREPAIRS

PASSED FAILED

CLOSED TIGHT CLOSED TIGHT OPENED AT       PSID AIR INLET       PSID

      PSID       PSID #1 CHECK       PSID CHECK VALVE       PSID

Detector Meter Reading:      

LINE PRESSURE       PSI CONFINED SPACE? YES NO

REMARKS:      

TESTER’S SIGNATURE: CERT #: DATE:      

TESTER’S NAME PRINTED: TESTERS PHONE #

REPAIRED BY:       LIC. #: DATE:      

FINAL TEST BY:       CERT #:       DATE:      

CUSTOMER’S SIGNATURE: DATE:      

CALIBRATION DATE: GAUGE #: SERVICE RESTORED? YES NO

      BACKFLOW PREVENTION ASSEMBLY TEST REPORT

NAME OF PREMISE       Commercial Residential

SERVICE ADDRESS                  

CUSTOMER PRINTED NAME       PHONE       FAX      

LOCATION OF ASSEMBLY      

TYPE OF HAZARD ISOLATED       DCVA RPBA OTHER

NEW INSTALLATION EXISTING REPLACEMENT LINE PRESSURE:       PSI

MAKE OF ASSEMBLY       MODEL       SERIAL #       SIZE ”      

AIR GAP INSPECTION: Required minimum air gap separation provided? Yes No PROPER INSTALATION? YES NO

INITIAL TEST

PASSED

FAILED

DCVA / RPBACHECK VALVE #1

DCVA / RPBACHECK VALVE #2

RPBA PVBA / SVBA

LEAKED CLOSED TIGHT

      PSID

LEAKED CLOSED TIGHT

      PSID

OPENED AT       PSID AIR INLETOPENED AT       PSID

#1 CHECK       PSID

AIRGAP OK?       DID NOT OPEN

NEW PARTSAND

REPAIRS

CLEAN REPLACE PART CLEAN REPLACE PART CLEAN REPLACE PART CHECK VALVEHELD AT       PSID                 

                  LEAKED

                  CLEANED

                  REPAIRED

TEST AFTERREPAIRS

PASSED FAILED

CLOSED TIGHT CLOSED TIGHT OPENED AT       PSID AIR INLET       PSID

      PSID       PSID #1 CHECK       PSID CHECK VALVE       PSID

Detector Meter Reading:      

LINE PRESSURE       PSI CONFINED SPACE? YES NO

REMARKS:      

TESTER’S SIGNATURE: CERT #: DATE:      

TESTER’S NAME PRINTED: TESTERS PHONE #

REPAIRED BY:       LIC. #: DATE:      

FINAL TEST BY:       CERT #:       DATE:      

CUSTOMER’S SIGNATURE: DATE:      

CALIBRATION DATE: GAUGE #: SERVICE RESTORED? YES NO

FIRE ALARM SYSTEM (One System per Report)

CTF 8005 System Status Given

CONFIDENCE TEST REPAIRS RED YELLOW GREEN

Frequency Annual: Semi-Annual: Quarterly:Date of Inspection:

Occupancy Information Occupancy Name: Occupancy Address:

Building Owner: Phone Number: Owner Address:

Contact Person: Phone Number:

System Information (where applicable) Central Station Monitoring Yes No Monitoring Company Name:

Control Panel Manufacturer: Model Number:

Location of System:

Testing Agency Information Fire Protection License: Washington State Contractor License: NICET Number:

Testing Agency Name:

Address:

Phone:

E-mail:

Problems Found: (Explain any “no” responses and use additional paper if needed)

Corrections Made:

Date Corrected: _________ Corrected by: (Print) (Sign) This report certifies this fire and life safety system has been properly inspected for reliability to cover the items listed in the report and is consistent with NFPA 72 Standard. All discrepancies are noted and have been reported to the building owner or responsible person for corrective action.

TECH NAME: (Print) (Sign) Date:

Building Representative: (Print) (Sign) Date:

AAA FIRE & SAFETY INC. 3013 3rd Ave N., Seattle WA 98109

(206) 284-1721

AAA FIRE & SAFETY, INC.3013 3RD AVE NORTHSEATTLE, WA 98109

"THE NORTHWESTS MOST TRUSTED NAME IN FIRE PROTECTION"

Tacoma Fire DepartmentConfidence Test Officer 253.591.5740

FAX Number 253.594.7943 Red Tag FAXLINE Number 253.591.5034

3471 S. 35th St. Tacoma, WA 98409

The items on the checklists below shall be inspected and tested. This list does not constitute all of the required inspecting and testing of the fire and life safety system. Refer to the NFPA 72 Standard for inspecting and testing requirements.

ALARM SYSTEM FUNCTIONALITY YES NO Trouble signal with AC power off? System operates properly on battery backup? Battery voltage (no load) _________ volts Battery voltage (full load) (signals operating) _________ volts (signals operating) Charge circuit voltage _________ volts System operates properly on standby power? All signals operate on AC power Number of initiating circuits: Number of signal circuits: Does the system meet audibility standards? All circuits checked for electrical supervision? All auxiliary equipment operates (Elevators, fans, dampers)? N/A Ventilation controls operate? N/A Key to panel available? Operating instructions at panel? The elevator call down functions properly? N/A Test record posted at panel? General alarm automatic time delay __________ (minutes) N/A Other devices (specify) __________ Was a full walk through done?

Test Results Acceptable System Devices Total Number of Units inBuilding

Total Number Units Tested N/A YES NO

Bells, Horns & Chimes Voice Speakers (voice clarity) Operations Test

1. Smoke Detector2. Duct Detector

Sensitivity Test 1. Smoke Detector2. Duct Detector

Heat Detectors Sprinkler Flow Switches Sprinkler Supervisory Switches Visual Alarm Devices Manual Pull Stations Automatic Door Unlocks Automatic Door Release

Test Acceptable Communication Equipment Total Number of Units in Building

Total Number Units Tested N/A YES NO

Phone Sets Phone Jacks Call-in Signal

STAIRWAY DOOR LOCKS

SYSTEM FUNCTIONALITY YES NO

Number of stories? ________

Do all locking devices release upon activation of the fire alarm system?

Do all locking devices release upon power failure?

Does the door to roof unlock?

Do doors unlock but not unlatch?

Is there an access key at the control panel for doors that fail to unlock?

Test Acceptable System Devices Total Number of Units in Building

Total Number Units Tested N/A YES NO

Electric Strike

Electric Bolt

Other locking devices

Building is not equipped with Stairway Door Lock system.

WET – AUTOMATIC SPRINKLERS(One System per Report)

CTF 8002 System Status Given

CONFIDENCE TEST REPAIRS RED YELLOW GREEN Frequency 5 Year: Annual: Semi-Annual: Quarterly:

Date of Inspection: Occupancy Information

Occupancy Name: Occupancy Address:

Building Owner: Phone Number: Owner Address:

Contact Person: Phone Number:

System Information (where applicable) Central Station Monitoring Yes No Monitoring Company Name:

Control Panel Manufacturer: Model Number:

Location of Riser:

Max Height # of Heads System # TFD System #

Testing Agency Information Fire Protection License: Washington State Contractor License: NICET NUMBER:

Testing Agency Name:

Address:

Phone:

E-mail:

Problems Found (Explain any “no” responses and use additional paper if needed):

Corrections Made:

Date Corrected: ________ Corrected by: (Print) (Sign) This report certifies this fire and life safety system has been properly inspected for reliability to cover the items listed in the report and is consistent with NFPA 25 Standard. All discrepancies are noted and have been reported to the building owner or responsible person for corrective action.

TECH NAME: (Print) (Sign) Date:

Building Representative: (Print) (Sign) Date:

(2

Washington State Inspector's License:

AAA FIRE & SAFETY, INC.3013 3RD AVE NORTHSEATTLE, WA 98109

"THE NORTHWESTS MOST TRUSTED NAME IN FIRE PROTECTION"

Tacoma Fire DepartmentConfidence Test Officer 253.591.5740

FAX Number 253.594.7943 Red Tag FAXLINE Number 253.591.5034

3471 S. 35th St. Tacoma, WA 98409

The items on the checklists below shall be inspected and tested. This list does not constitute all of the required inspecting and testing of the fire and life safety system. Refer to the NFPA 25 Standard Inspection, Testing and Maintenance of Water Based Fire Protection Systems requirements.

SYSTEM FUNCTIONALITY

Was a full walk through performed? Yes No

Is building fully sprinkled? Yes No

Is there a calculation plate? Yes No

What is the design density? (gallons per sq ft.)_______________

Main drain flow test conducted? Yes No

Static pressure: __________ psi Residual Pressure: __________ psi Test pipe size? ___________

Flow switches, supervisory switches and alarm bells tested satisfactorily N/A Yes No

Water motor gong operates properly? N/A Yes No

System is free of any recalled heads? Yes No

Pressure regulating valves tested satisfactorily? N/A Yes No

Valves are locked or supervised? Yes No

Signs are provided on control valves? Yes No

Sprinkler heads are less than: 1. 50 years for Standard Response Yes No 2. 20 years for Fast Response N/A Yes No 3. 10 years for Dry Type N/A Yes No 4. 5 years for solder type with extra high temperature rating N/A Yes No 5. A sample has been successfully tested within the last 10 years Yes No

Sprinkler heads free of corrosion, paint, obstructions and/or physical damage? Yes No

Proper number of spare sprinkler heads available? Yes No

Sprinkler wrench available for each type of sprinkler? Yes No

Minimum of 18” clearance between top of storage and sprinkler deflector? Yes No

Did antifreeze systems test satisfactorily? N/A Yes No

Is building adequately heated? Yes No

System left in service with an inspection tag posted main valve? Yes No

System gauges replaced or calibrated every 5 years? Yes No

Fire Department Connection in satisfactory condition, couplings free, caps in place, check valves tight? Yes No

Was the Fire Department Connection (FDC) internal inspection completed? (req every 5 years) Date: Yes No

Was debris found in the Fire Department Connection (FDC)? Yes No When was an internal pipe inspection performed? (req every 5 years) Date: ______________

CPVC N/A

Yes No

Testing agency has informed owner of legal obligation to perform inspections, testing and maintenance in accordance with NFPA 25.

Yes No