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Business Name:
Address:
City, State, Zip:
Contact Name:
Contact Phone:
Contact Email:
Inspection Date:
Name:
Address: Owner Date:
City: Fire AHJ Date:
State: Contractor Date:
Telephone:
CA License #:
Performed by:
Performed by:
N/A Fail Pass
FAIL
Yes No
Property Information:
NFPA25 as amended by CCR, Title 19
Inspection, Testing, and Maintenance Cover Sheet
SimplexGrinnell
Construction Type:
Year Constructed:
835 College Ave., College of Marin
Heidi Rank
12/14/2015
E
Type II-A
Occupancy/Use:
No. Stories:
LRC
Kentfield, CA 94904 2
June-84
415.485.9645
Number of System Risers: 1Contractor Information:
[email protected] Service Request #: 33839928
Copy sent to:
Check box for each system inspected and enter the number of forms used for inspection.
Check boxes (Fail or Pass) to indicate status of inspected system at end of inspection.
NFPA 25 Chapter Number of FormsForms Included with this Report
707-578-3212
986047
Joseph Gurrola
12/14/15
12/14/15
3077 Wiljan Ct. Ste. B
Santa Rosa
California
5 Automatic Sprinkler System
Standpipe and Hose System 6
Private Water Supply System 7
Fire Pump 8
Concerns that are Not Deficiencies (i.e. Non-Sprinklered Areas)
*See "Deficiencies and Comments" section at end of each respective form.
5 Year Certification: NONE
NOTES:
1) For specific inspection, testing, and maintenance requirements &
information, see NFPA 25, 2011 edition as amended by California Code of
Regulations, Title 19, §901 to §906. 2)
Inspection items may be performed by the owner in accordance with
California Code of Regulations, Title 19, §904.1(a)
Foam Water Sprinkler System 11
Water Mist System 12
Water Storage Tank 9
Water Spray System 10
Name: Name:
Address: Address:
City, State, Zip: City, State:
Contact Name: Phone #:
Telephone: SR #:
Email: Misc:
Riser No.
Riser
Diameter
Main Drain
Diameter
Initial Static
Pressure
Residual
Pressure
Final
Static
Pressure P,F,N/A
1 3 in 1 1/4 in 130 115 130 FAIL
1.1 I PASS
1.2 I PASS
1.3 I PASS
1.4 I PASS
1.5 I PASS
1.6 I N/A
1.7 I N/A
1.8 I PASS
1.9 I N/A
1.1 I N/A
1.11 I N/A
1.12 I PASS
1.13 I PASS
1.14 I N/A
1.15 I N/A
1.16 I N/A
1.17 I N/A
1.18 I N/A
415.485.9645
LRC
835 College Ave., College of Marin
License # 986047
SFM
CSLB
Contractor or Licensed Owner Information
SimplexGrinnell
3077 Wiljan Ct. Ste. B
Santa Rosa, California
707-578-3902
Main Drain Test (Annual)
5.2.8
5.1.6, 13.5.2, 13.5.5.1
Gauges (Wet Pipe Systems)
Enter Water Supply Pressure Below Riser Check
5.2.7
5.2.1.4
13.7
13.4.1
13.5.1.1
5.2.6
5.2.5
5.2.4.1
Control Valves – Identification Sign
Waterflow Alarm Devices
Supervisory Devices
13.3.1
13.3.2
5.2.5
Pressure Readings Acceptable
Quarterly &
Annual Report
Equipment/Electrical Room
Location / Description
California Code of Regulations - Title 19
Inspection, Testing, and Maintenance
Wet Pipe
Fire Sprinkler System
33839928
Heidi Rank
Kentfield, CA 94904
Property Information
Riser Information
Description
NFPA 25 CA ed.
Reference
Enter Water Supply Pressure Above Riser Check
Quarterly Inspections
5.2.4.1
5.2.4.1
5.2.4.1
Date Date 12/14/15Date
Item
Control Valves – Inspection
13.6.1
They do not include Class I, II, or III standpipe systems.
PRV – Fire Sprinkler Systems
Hydraulic Design Information Sign (For Hydraulically
Designed Systems)
General Information Sign (Not Required for System prior
to 2007 Edition of NFPA 13)
Heat Tape
Spare Sprinklers
Fire Department Connections
Alarm Valves – Exterior Inspection
Pressure Reducing Valves
Backflow Preventers
* Small hose connections are hose valves and optional hose supplied by the fire sprinkler system.
Small Hose Connections - Hose Valve*
13.5.1.1
Name:
Address:
City:
State
Zipcode:
SR #:
1.19 I 12/14/2015 P
1.2 I 12/14/2015 N/A
1.21 I 12/14/2015 F
1.22 I 12/14/2015 P
1.23 I 12/14/2015 P
2.1 T 12/14/2015 N/A
2.2 T 12/14/2015 N/A
2.3 T 12/14/2015 P
2.4 T 12/14/2015 P
2.5 T 12/14/2015 P
2.6 T 12/14/2015 P
2.7 T 12/14/2015 P
2.8 T 12/14/2015 P
2.9 T 12/14/2015 N/A
2.1 T 12/14/2015 N/A
3.1 M 12/14/2015 P
3.2 M 12/14/2015 N/A
Kentfield, CA 94904
* Small hose connections are hose valves and optional hose supplied by the fire sprinkler system.
They do not include Class I, II, or III standpipe systems.
SimplexGrinnell
3077 Wiljan Ct. Ste B
Santa Rosa
California
95407
33839928
FNo
3.4 M System Returned to Service 4.5.3 12/14/2015Yes
N/ANo
Small Hose Connections* 13.5.6.3
3.3 MObstruction Investigation required (If “Yes”, see
Deficiencies and Comments Section for Results.)14.3 12/14/2015
Yes
PRV – Fire Sprinkler Systems 13.5.1.3
Control Valves 13.3.4
Backflow Preventer Assemblies 13.6.2
Small Hose Connections w/PRV Hose Valves –
Partial Flow Test13.5.2.3
Control Valve – Operation 13.3.3.1
Supervisory Devices 13.3.3.5
Main Drain Test (Enter Data on Page 1 of this form) 13.2.5, 13.3.3.4 130-115-130
Control Valve - Position 13.3.3.2
Recalled Sprinklers If not present = Pass; If present =
FailTitle 19 904.1(c)
Water Flow Alarm Devices. 90 sec. maximum - (Enter
Time )5.3.3, 13.2.6 40 sec.
Seismic Braces 5.2.3
Field Service Test Required (Send Report to Fire
Code Official)5.3.1
If REQUIRED, Enter 'F'
until results are returned
from Lab
Pipe and Fittings 5.2.2
Hangers 5.2.3
Buildings (Freeze Protection) 4.1.1.1 Owner’s Responsibility
ANNUAL INSPECTION, TESTING, AND MAINTENANCEInclude ALL Quarterly Inspections
I = Inspection T = Test M = Maintenance P = Pass F = Fail N/A = Not Applicable
Item DescriptionNFPA 25 CA ed.
Reference Date Comments Only P,F,N/A
Wet Pipe California Code of Regulations - Title 19 Quarterly &
Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report
Sprinklers 5.2.1
Heidi Rank
415.485.9645
Property Information
License # 986047
Contractor or Licensed Owner Information
Name:
Address:
City, State, Zip:
Contact Name:
Telephone:
LRC
835 College Ave., College of Marin
Name: Name:
Address: Address:
City, State, Zip: City
Contact Name: State
Telephone: Zipcode:
Email: SR #:
Item Date Riser D C
5 year 12/14/2015 1 D
1.21 12/14/2015 1 D
3.3 12/14/2015 1 D
Signature on File-Heidi Rank
Customer: Inspector:
I hereby certify that the fire protection equipment listed above has been fully inspected, tested, and maintained on this date by
the company indicated above, in accordance with CCR, Title 19, Sections 901 to 906 and that the equipment is fully operable
except as noted in the “Deficiencies and Comments” section of this form.
See Correction Form AES 10 for corrected deficiencies.
Number Attached:
Number Attached:
Check here if additional Deficiencies and Comments are listed on Form AES 9.
Deficiencies and Comments Indicate all equipment, devices and parts that were repaired or replaced
D = Deficiency C = Comment (Indicate type )
No history of 5 year inspection
Item fails due to corrosion of pipe/fittings
Riser does not pass inspection due to corrosion
Kentfield, CA 94904 Santa Rosa
Heidi Rank California
415.485.9645 95407
33839928License # 986047
Wet Pipe California Code of Regulations - Title 19 Quarterly &
Fire Sprinkler System Inspection, Testing, and Maintenance Annual Report
Property Information Contractor or Licensed Owner Information
LRC SimplexGrinnell
835 College Ave., College of Marin 3077 Wiljan Ct. Ste. B
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