HomeMy WebLinkAboutFresco_Backflow Prevention TestFIRE SUPPRESSION SYSTEMS
2171 Industrial Drive Bozeman, MT 59715
Phone: (406) 586-9510 – Email: inquiry@firesuppression.net Bozeman~Billings
BACKFLOW PREVENTION ASSEMBLY TEST REPORT
CUSTOMER:________________________________________________
STREET ADDRESS:__________________________________________
MAILING ADDRESS:__________________________________________ LOCATION OF ASSEMBLY:____________________________________
TYPE OF ASSEMBLY:_____________________ SIZE:______________
MANUFACTURER:____________________________________________ MODEL:___________________ SERIAL NO:______________________
LAST TEST:________________ TEST DUE:______________________
HAZARD:__________________
Reduced Pressure Assembly RP DCDA
DC RPDA
Double Check Valve Assembly
PVB AIR GAP
SVB AVB
Check Valve #1 Check Valve #2 Relief Valve PVB/SVB
Initial
Test
Leaked Leaked AIR INLET
Closed Tight Closed Tight Did not Open Did not Open
Held at
______PSID Held at ______PSID Opened at _______ PSID Opened at _____ PSID
Repairs Cleaned Cleaned Cleaned CHECK VALVE
Replaced Replaced Replaced Leaked
Held at ________ PSID
Details Cleaned
Replaced
AIR INLET
Opened at _____ PSID
Final
Test
Closed Tight Closed Tight CHECK VALVE
Held at ______
PSID Held at ______ PSID Opened at _______ PSID Held at ________ PSID
Comments: Line Pressure
Meter Reading
Held Backpressure
#2 Shutoff
The above report is certified to be true
Relief Valve Exercised
Date Tester Signature Tester # Test Kit Passed Failed
Initial
Test
Repairs
Final
Test
FRESCO CAFE, INC.
317 E MENDENHALL
317 EAST MENDENHALL
Basement
Reduced pressure 1"
Watts
009M2QT 364709
5/2018 8/19/2020
Domestic
8.6 2.2
Water meter s/n 1850223520
8/19/2020 Mike Milton 27-2001122 04100435
n n
4/14/2016 MI
KITCHEN HOOD FIRE SUPPRESSION
SYSTEM REPORT
Monitoring Yes No N/A Monitoring Notes
System Supervised by Fire Alarm System?
Monitoring company? Account Number Account Password
Signals to fire panel not tested per customer: Printed name: Signature
COOKING APPLIANCE LOCATIONS (LEFT TO RIGHT):
YES NO N/A YES NO N/A o o o 1. All appliances properly covered w/correct nozzles o o o 18. Proper nozzle covers in place
o o o 2. Duct and plenum covered w/correct nozzles o o o 19. Check travel of cable nuts/S-hooks
o o o 3. Check positioning of all nozzles o o o 20. Piping & conduit securely bracketed
o o o 4. Hood/duct penetrations sealed properly o o o 21. Proper separation between fryers & flame
o o o 5. Check if seals intact, evidence of tampering o o o 22. Proper clearance - flame to filters
o o o 6. Has system been discharged since last inspection o o o 23. Exhaust fan in operating order
o o o 7. Pressure gauge in proper range (if gauged)o o o 24. All filters replaced
o o o 8. Check cartridge weight (if applicable)o o o 25. Fuel shut-off in on position
o o o 9. Inspect cylinder and mount o o o 26. Manual & remote set/seals in place
o o o 10. Operate system from terminal link o o o 27. Fuse Links or Bulbs Replaced
o o o 11. Test for proper operation from Pull Station o o o 28. Personnel instructed in manual operation of system
o o o 12. Check operation of Micro Switches o o o 29. Slave system operational
o o o 13. Check operation of gas valve o o o 30. Clean cylinder & mount
o o o 14. Electric Shunt Trip Operated Properly o o o 31. Fan warning sign on hood
o o o 15. Make Up Air Shut Down o o o 32. Replace system covers
o o o 16. Check and Clean Links/Bulbs o o o 33. System operational & seals in place
o o o 17. Clean Nozzles o o o 34. Service tag on system
Notes:
________________________________________________________________________________________
Deficiencies:_________________________________________________________________________________
____________________________________________________________________________________________
On this date, the above system was tested and inspected in accordance with procedures of the presently adopted editions of NFPA 17,
17A, 96 and the manufacturer’s manual and was operated according to these procedures with results indicated above.
SERVICE TECHNICIAN ENDORSEMENT # DATE CUSTOMER’S AUTHORIZED AGENT
FIRE SUPPRESSION SYSTEMS
2171 Industrial Drive, Bozeman, MT 59715 Phone: (406) 586-9510 Email: Inquiry@FireSuppression.net
Bozeman~Billings
LOCATION OF SYSTEM CYLINDER(S): _____________________
MANUFACTURER/MODEL #: ______________________________
SYSTEM UL 300 LISTED: o YES o NO
MANUFACTURE/LAST HYDRO DATE_______________
Cartridge Part Number____________ Date___________
FUSIBLE LINKS: o BULB LINKS: o
TEMP: 360 DEG o QTY: ________________________ 450 DEG o QTY: ________________________
500 DEG o QTY: ________________________ OTHER o _____________________________
FUEL SHUT-OFF: o ELECTRIC o GAS
FUEL SHUT OFF NOT TESTED PER CUST REQUEST: o
CUSTOMER INITIALS: _____________________
CUSTOMER:
ADDRESS:
CITY:
DATE OF SERVICE:
TYPE OF SERVICE: o ANNUAL o SEMI-ANNUAL
o INSTALLATION o RECHARGE o REPAIR
/
Kitchen wall
Kidde WHDR-260
CAFE FRESCO 03/2020
317 E MENDENHALL
4
87-120043-001 9/2017
BOZEMAN
4
4
4
4
3MT59715
08/19/2020 11:30am MDT
6 burner range Flattop/salamander 2 burner range
44
4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
4 4
Replaced cylinder
4
001389 8/19/2020
4
Mike Milton