10015 EDMONDS WAYWwpe
HOME OF THE VALUE INSPECTION PROGRAM
WA Contractor CINTAFP904DJ/Electrical CINTAFP9030K
INDUSTRIAL ' COMMERCIAL ' BONDED ' INSURED
ph: 253.852.1962 fax 253.852.1962
3320 West Valley Hwy N, D111 • Auburn WA 98001
CUSTOMER
Name $�lv
Address kms Ewc ">
City 1 D
wl
Telephone 4-73527 0Store # `�
Owner or
Alarmed: ❑ Yes I0No Monitoring Co.
Signal Rec'd: 13 Yes Y"w' Phone #
Restoral Rec'd: O Yes Vlo Time
cooking Appliance Locations: Left to Right
Conditions Found on Arrival
1. Date Last Service II I2A�T_
2. Tamper Seals Intact .................................................
3. Any Filters Missing or Broken? ................................
4. Filters Conform to NFPA 96 or Hood Type ................
5. Remote/Manual Pull Obstructed ..............................
6. System Discharged ..................................................
7. Pressure Gauge in Proper Range ............................
8. New Appl/Appl Moved Since Last Service ...............
9. All Appl Properly. Covered w/Correct Nozzle............
10. Hood & Duct Penetrations Properly Sealed .............
11. Distribution Piping Secured & Unobstructed ............
12. Detectors & Conduit/Cable Secured & o ucted
13, Cylinder Hydrostatic Test Due Date
14. Cylinder Six Year Maintenance
15. Nozzle Seals Missing or Plugged? ..........................
16. Fryer/Salamander Flue to Filter 18" Min? NFPA 96..
17. Charbroiler Clearance Flame to Filter (3.5' IMC)......
18. Links Covered with Grease .....................................
COMMENTS
10015
V
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made to provide the perfect service to our custorners.
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RANGE HOOD FIRE SYSTEM
INSPECTION & SERVICE
REPORT
DATI,,01 SERVICE
TIM
AM
PM
`�
A N AL
SEMI-ANNUAL
RECHARGE
INSTALLATION
RENOVATION
VL-
LOCATIO OF SYSTEM CYLINDERS
MANUFACTURER
MODEL NUMBER
WET CHEM
UL 300
DRY CHEM
l ,2
�
off.
C CINDER SIZE MASTER
CYLINDER'SIZE SLAVE
CYLINDER SIZE SLAVE
-
FUSE LINKS 350 F
FUSE LINKS 450 F
FUSE LINKS 500 F
OTHER
Z
FUEL SHUT-OFF
ELECTRIC
GAS
SIZE
�
>�
SERIAL NUMBER
LAST HYDRO TEST DATE
LAST RECHARGE DATE
Grease Accumulation
Clean Moderate Heavy Excessive
Plenum
Duct
Filters r1
Date Last Cleaned
Cleaning Cycle Recommended
Cleaning Company Phone #
Yes No N/A
Service Performed
19. Manual Pull Operation ................................................
20. Operate System From Terminal Link ...........................
21. Check Operation of Micro-Switch(s) ...........................
22. Exhaust Fan in Operating Order/Continues to Operate.
23. Make Up Air Shuts Down ......................... ...........
24. Check Oper. of Gas Value Mech_Elect
25. All Appliances Shut Down - Gas & Elect .....................
26. Agent Checked, Powder or Liquid ...:..........................
27. Cartridge Weight Within 1/2 oz (If Appl)......................
28. Clean Nozzles & Cover Seals in Place .......................
29. Gas Valve Reset -Relight Pilot Light(s) ................:....
30. Replace Fuse Links Mfg. Date
31. All Filters Replaced ....................................................
32. Reset System/Remove All Safety Devices ..................
33. System Operational/Cover & Seals in Place ...............
34. Exhaust Fan Warning Sign on Hood......... ��..../r<�.......
35. Kitchen FEX Svc'd per NFPA 10. Type
36. Staff Instructed in Manual Oper. of System .................
37. Kitchen FEX Mounted Within 30'...........................:....
38. System Installed According to Mfg. Spec ....................
39. Hood & All Appliances Protected ................................
40. Service Tag on System ...............................................
The Service Technician on this Date Operated, Tested & Inspected this System in Accordance with Procedure of NFPA 17. 17A, 96 & the Manufacturers Manilal.
Results/Conditions Listed Above.
E /VIICETEC CIAAN`• DATE/ TIME AM I PM CUSTOMER'S AUTHORIZED AGENT
Note: Fire Code requires a copy of this report to be mailed to Authority having Jurisdiction.
White Copy - Customer • Yellow Copy - Distributor • Pink Copy - Authority having Jurisdiction