10124 EDMONDS WAY_1012-Y F-J)MOA.)i)f (,J)'J/
From:SANDERSON FIRE PROTECTION To:4257710221
JUJANSUL].
McDonald's Restaurant:
Nil
� 'W( V�
Store No.
Licensee MCCopco
Store Manager t/
Address _ _ Z012 / Z4ma*1 s
City, State
lip Code 9%02-0 Phone
11/16/2017 12:02 #357 P.001/001
FIRE SUPPRESSION SYSTEM ECKLIST
Date / ��
Authorized ANSUL Distributoo :
Company SavtGt Cr50✓/i- I�D�`�C7i(/!�
Address
City, State 7Z eC,,- T G✓d�
Zip Code 9Y7A Phone$06)
Inspected By
COOKING STATION/FIRE SYSTEM INFORMATION
HOOD 1
4
Cooking Equipment Identification (e.g. 1G, 2G, 2V, 3V, 4V, Combo, Other)
R-102 System Size (e.g. 3 gal., 6 gal., Other)
"2HOOC�4HOOD
Last R-102 Tank(s) Hydro Date(s)System
is UL 300 Compliant (Yes/No)
Note: Only genuine ANSUL components that are evaluated and included in the R-102 UL 300 systems listin� and installed in accordance with the R-102 System
Design, Installation, Recharge, and Maintenance Manual (Part No. 418087) are allowed. "UL Classified" or generic components may not be substituted. The only
exception Is for pipe, conduit, related fittings, and chrome sleeving (when required).
Date of Tanks: Mild Steel (Cty) Date(s)
Stainless Steel(Oty) _ Date(s) Z
CHECK TYPE OF SERVICE PERFORMED:
❑ New Installation/Rebuild ❑ Seml-Annual Maintenance al Maintenance ❑ 12-Year Maintenance ❑ Recharge
�e AAISUL R-102 Fire Suppression System(s) is installed, serviced, and/or recharged in accordance with the current R-102 System Design, Installation,
Recharge, and Maintenance Manual (Part No. 418087), NFPA 17A, NFPA 96, and all applicable local.codes.
❑ Service Refused (by store Owner/Operator). Current Service Provider
SERVICE PARTS
No. of Nozzle Caps Replaced:
Fusible Links Replaced (Oty): 165° 212'
Verify genuine ANSUL cartridge seal is present:s
Verify proper portable extinguishers are present:
Dry Chemical Units:
Model # f:92!fj� Last Hydro Date
Model # ��� Last Hydro Date
K-Class Units/F-Class its (where applicable):
Model # lC Last Hydro Date
Model # 24SS Last Hydro Date
280` 360° 3 450° 500° —
❑ No - if no, replace with new cartridge.
Model if 15WC Last Hydro Date
Modelif Last Hydro Date
Model # Last Hydro Date
Model # Last Hydro Date
Note: Based on local code requirements, other tests or services may need to be performed.
I certify that the restaurant fire suppression system(s) is installed in accordance with the R-102 System Design, �es ❑ Yes/exception ❑ No
Installation, Recharge, and Maintenance Manual (Part No. 418087).
1 Certify that only genuine ANSUL components are present and that "UL Classified" or generic parts have not been substitutedO�Yes ❑ Yes/exception ❑ No
It any part of the system service could not be performed, or "Yes/exception" was indicated above, explain: .
SERVISIE TdCHNICIAN NAME (PRINT)
G
STOR MANAGER NAME (PRINT)
SERVICE TECHNICIAN SIGNATURE
STORE MANAGER SIGNATURE
ORIGINAL — TYCO FIRE PROTECTION PRODUCTS CANARY — McDONALD'S MANAGER . ' PINK - DISTRIBUTOR
't'yCq One Stanton Street / Marinette, WI 54143-2542, USA / +1-715-735-7411 / www.ansul.com
Fire Protection Products Copyright 0 2015 Tyco Fire Products LP. / All rights reserved. / Form No. F-2011200-03