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For Information Regarding t is Report ���_���������� <br /> � � Please Call ������ �������0�� ������ <br /> 800-522-7150 <br /> � . <br /> �fP'�lbfastE�I�` t <br /> MNSTERPF07ECTION,IP SRO# � (� Date � — � 2 ` 1� <br /> ❑QUARTERLY ❑ANNU�.L ❑SEMI-AfdNUAL ❑ EW IN TALLATIOM ❑ FIRST IMSPECTION ❑ CHANGES MADE <br /> Customer �' (f e[�� �°j p I p V��- . Cusfomer# <br /> /� <br /> Address � � 0 , , d Gl.� � � d� " � / .f. � � s� <br /> Manager/Owner hone f J? � � �,2 � <br /> System Location �� C �''/t/ fVlanufacturer ��`j'Cf�� nllodel C � #Cylinders <br /> Cylinder size(s) /' � NAethod of Actuation � ,� Number Degree ��� <br /> List main cylinder size first (' <br /> Last Hydro � ;� Last Recharge � Seri I fdumber �� ��j S Fuel Type <br /> Restaurant nAarine❑ Industrial❑ Inspected per I stallation Elec❑ Gas❑ <br /> f�l nual Date Size � � <br /> . 4 � I . <br /> . � <br /> ,. ..... ... ...... ... ... ... .. ..................................................................................................................... ... ...... ..... .... ......... .. ., <br /> : ... .. .. ..... ............ ................ .............................. s............ ..............�........................................... .. ... ... ... ... ....... .. <br /> ... ... ..... ......... ....... . ....... ... �.. . ...... ....�. .��. ... .. ......... ... ........ ... .... .. ... ....... , <br /> .:. ......... ... ..... ........... .. ...... .. ..... ... .. ... ... ... ... ......... ... .... : <br /> . t <br /> ' �p <br /> ... ... ... ... ...... ... ....... . . ..... ......... .... ..... ... ... ... <br /> . . <br /> . ... ......... .. .. .... <br /> : , <br /> .... ... .... .. ... ... . ...... . .. . <br /> . <br /> ���/' � ��t""� �� �j YES NO N/A <br /> � Is system mounting bracket in accessible location and soundly mounted? ./.. , 4 / ❑ � <br /> I - ❑ ■ <br /> 2. Is piping tight,secured and checked for blockage?.. ......... ........... ...... ............ ............. ............. .... ... <br /> 3. Are grease tights installed at all hood penetrations? ..... ........... .... ....... ........ ...t............. ....... ... ❑ � <br /> 4. If multiple systems,did all systems operate satisfactory? ...... ... ......... ..... ... ...... ........... ... ....... .... ... ... <br /> 5. Is system properly installed to properly protect hazard(s)?... ... .......... ... ... ..... ... ..... ............ .... ❑ ❑ � <br /> � <br /> 6. Are all nozzles properly located and proper type?..... ......... ............. .............. ... ... .... ... <br /> 7 Is manual pull operational and in proper location? ... ..... ... ................ .... ... ...... ... ....... ... ... .... ❑ ❑ <br />', 8. Are all fusible links or HAD's of proper temperature rating? ... ............ ....... ....... ... .... .... ........ .............. ... <br /> 9. Were fusible links replaced? ... .... ... .... ..... ... .......... .... ... .......... ....... .... ❑ ❑ <br /> 10. Is automatic detection operational?... ....... ... ... ... ........ .... .......... ......... ... ......... ... .................. ..... ...... ❑ ❑ <br /> � 11 Did fuel shut off properly?.... ..... ... ....... ..... ... ....... ...... ...... ... ...... ... ... ........ ...... ... .. ❑ ❑ <br /> 12. Did all electric shut down under hood(s)and alarms operate?.... ......... .............. ... ... .... ... ...... ... ...... ...... ................. ' ❑ ❑ <br /> 13. Are bursting disc and chemical in good condition?... .... ....... ........ .. ..... ... ... ......... ... ....... .......... ............. ....... . ❑ ❑ <br /> 14 Is cartridge within proper weight? .............. ... ................. ...... ......... ... ... ...... ...... ..... ... ... ..... ......... ❑ � <br /> 15. Are all nozzles clean and caps/seals properly installed? ..... ...... ...... .... ... .... ..... ..... ... .......... ..... .... � ❑ ❑ <br /> 16. Is cylinder pressure in operational range? ... ... ........... ........... .. ..... ...... ...... ... ...... ..... ....... .............. ......... .... � ❑ ❑ <br /> 17 Are filters clean and in good condition?........ .... ... .......... .. ... ............ ... ... ... ....................... ... ... � ❑ ❑ <br /> 18. Was system placed back in service and in normal operation condition? ........... .... ... ...... ...... ... ......... ... ... ..... ... ......... ❑ ❑ <br /> 19. Have persons working in area been instructed on proper operation of system?...... ........... ........ ... .... .... ........ ... ... ..... ❑ � <br /> 20. Was the inspection/maintenance performed in accordance with NFPA 77,17A and 96? ...... .................. ... ............... .... .......... ❑ ❑ <br /> 21 Was inspection/maintenance performed in accordance with manufactures sp cifications?...... ... ......... ....... ... ... .... .. <br /> ❑ ❑ <br /> 22. Does system comply with UL300?... ... ........ ... ......... .... .... ............ ... ..... ....... ... ..... ....... ... .. ❑ ❑ <br /> 23. Was system tagged in accordance with 69A-21?(Florida only) ... ...... .. .... ...... .......... ... .... ..... .... ......... ..... � ❑ ❑ <br /> Comments � r,y� <br /> .� <br /> 1,THE UNDERSIGNED,CERTIFY THAT I PERSONALLY INSPECTED THE ABOVE PREMISES ND FOUND CONDITIONS AS NOTED <br /> PermiVLicense N <br /> Service Technician Date Time C to r S� nature Date <br /> `-' •• ,�, L � CJ AM Z' � <br /> FL 10 (9/12 Form X-P$I l�Ut I C(Ji-� COPY <br />