Inspection, Testing, and Maintenance Cover Sheet

1 inspection , Testing, and Maintenance Cover SheetNFPA25 as amended by CCR, Title 19 Property Information: Name: Occupancy/Use: Address: Construction Type: City: No. Stories: ZIP: Year Constructed: Contact: Telephone: Contractor Information: Number of System Risers Name: Copy sent to: Address:OwnerDate: City: Fire AHJ Date: State: Contractor Date: Telephone: NOTES: 1) For specific inspection , testing, and maintenancerequirements and information, see NFPA 25, 2011 edition as amended by California Code of Regulations, Title 19, 901 to ) inspection items may be performed by the owner inaccordance with California Code of Regulations, Title 19, (a) CA License#: Job #: Performed by: 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 Included with this ReportNFPA 25 ChapterNumber of FormsN/AFail*Pass Automatic Sprinkler System5 Standpipe and Hose System6 Private Water Supply System7 Fire Pump8 Water Storage Tank9 Water Spray System10 Foam Water Sprinkler System11 Water Mist System12 Concerns that are Not Deficiencies ( Non-Sprinklered Areas)

2 Yes No*See "Deficiencies and Comments" section at end of each respective 1 September 3, 2013 Corrective Action and Repairs PerformedCalifornia Code of Regulations - Title 19 inspection , Testing, and Maintenance1 of 1 Property InformationContractor or Licensed Owner InformationBuilding #PhoneContact PersonSFMJob # Form #DateFoundDateCorrectedDeficiencies and CommentsIndicate all equipment, devices and parts that were repaired or replacedI hereby certify that the fire protection equipment listed above has been corrected in accordance with CCR, Title 19, Sections 901 to 906 and that the equipment is fully RepresentativeTechnicianSignatureSignatu reForm AES 10 Sept. 3, 2013 DateDateWet PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and MaintenanceQuarterly andAnnual Report1 of 3 Property InformationContractor or Licensed Owner InformationBuilding #PhoneContact PersonSFMJob # InformationMain Drain Test (Annual) DrainDiameterInitial StaticPressureResidualPressureFinal StaticPressureP,F,N/AThis building has more than 5 risers.

3 See additional AES form of AES forms attachedQuarterly InspectionsI = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA valves Identification valves inspection Alarm Devices (Wet Pipe Systems) Water Supply Pressure Below Riser Water Supply Pressure Above Riser Readings Design Information Sign (For Hydraulically Designed Systems) Information Sign(Not Required for System prior to 2007 Edition of NFPA 13) Department valves Exterior Reducing Hose Connections - Hose Valve* , Fire Sprinkler *Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II, or IIIstandpipe AES 3, 2013 Wet PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and MaintenanceQuarterly andAnnual Report2 of 3 Property InformationContractor or Licensed Owner InformationBuilding NameNameAddressJob #CityANNUAL inspection , TESTING, AND Maintenance Include ALL Quarterly Inspections I = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA ed.

4 ReferenceDateComments OnlyP,F, (Freeze Protection) s and Service Test Required (Send Report to Fire Code Official) If REQUIRED, Enter 'F' until results are returned from Sprinklers If not present = Pass; If present = FailTitle (c) Flow Alarm Devices 90 sec. maximum-(Enter Time ) Drain Test (Enter Data on Page 1 of this Form) Valve - Valve Preventer Hose Connections* w/PRV Hose valves Partial Flow Fire Sprinkler Control Small Hose Connections* Investigation required (If Yes , see Deficiencies and Comments Section for Results.) Yes Returned to Yes No* Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II, or IIIstandpipe = Deficiency C = Comment (Indicate type )ItemDateRiserDCDeficiencies and CommentsIndicate all equipment, devices and parts that were repaired or replacedForm AES 3, 2013 Wet PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and MaintenanceQuarterly andAnnual Report3 of 3 Property InformationContractor or Licensed Owner InformationBuilding NameNameAddressJob #CityD = Deficiency C = Comment (Indicate type )ItemDateRiserDCDeficiencies and Comments (cont.)

5 Indicate all equipment, devices and parts that were repaired or replacedCheck here if additional Deficiencies and Comments are listed on Form AES 9. See Correction Form AES 10 for corrected attached:Number attached: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 box if Annual inspection , Testing & Maintenance Items are Completed in the Indicated QuarterQuarter1st -Annual2nd - Annual3rd - Annual4th - AnnualDatePrint NameSignatureForm AES 3, 2013 Wet PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and Maintenance5-YearReport1 of 3 Property InformationContractor or Licensed Owner InformationBuilding #PhoneContact PersonSFMJob # InformationMain Drain Test (ANNUAL) DrainDiameterInitial StaticPressureResidualPressureFinal StaticPressureP, F, N/AThis building has more than 5 risers.

6 See additional AES form of AES forms attached:5-Year inspection , TESTING, AND MAINTENANCEI ncludes ALL Quarterly and Annual Inspections, Tests, and Maintenance Items I = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA DateComments OnlyP, F, valves Identification valves inspection Alarm (Wet Pipe Systems) Design Information Sign (For Hydraulically Designed Systems) Water Supply Pressure Below Riser Water Supply Pressure Above Riser Readings Information Sign (Not Required for System Prior to 2007 Edition NFPA 13) Department valves Exterior Reducing AES 3, 2013 Wet PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and Maintenance5 YearReport2 of 3 Property InformationContractor or Licensed Owner InformationBuilding NameNameAddressJob #CityANNUAL inspection , TESTING, AND Maintenance Include ALL Quarterly Inspections (See AES )I = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA OnlyP,F, Hose Connections - Hose Valve* , Fire Sprinkler (Freeze Protection) s - Accessible Concealed and and Fittings - Accessible Concealed - Accessible Concealed Braces - Accessible Concealed AreasCFC Yes Service Test Required Send Report to Fire Code REQUIRED, Enter 'F' until results are returned from Sprinklers If not present = Pass.

7 If present = FailTitle (c) Flow Alarm Devices 90 secs max. Enter Drain Test(Enter data on Page 1 of this form) Valve - Valve Preventer Hose Connections* w/PRV Hose valves Partial Flow Fire Sprinkler Gauges - Hose Connections* * Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II, or IIIstandpipe AES 3, 2013 Wet PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and MaintenanceProperty InformationContractor or Licensed Owner InformationBuilding NameNameAddressJob #CityANNUAL inspection , TESTING, AND Maintenance Include ALL Quarterly Inspections (See AES )I = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA OnlyP,F, valves - Internal - Pipe inspection - See Deficiencies and Comments Section for Yes Investigation Required.

8 If "Yes", See Deficiencies and Comments Section for Returned to Yes NoD = Deficiency C = Comment (Indicate type )ItemDateRiserDCDeficiencies and CommentsIndicate all equipment, devices and parts that were repaired or replacedCheck here if additional Deficiencies and Comments are listed on Form AES 9. See Correction Form AES 10 for corrected deficiencies. Number attached:Number attached: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 NameSignatureDateForm AES 3, 20135 YearReport3 of 3 Dry PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and MaintenanceQuarterly andAnnual Report1 of 3 Property InformationContractor or Licensed Owner InformationBuilding #PhoneContact PersonSFMJob # InformationMain Drain Test (Annual) DrainDiameterInitial StaticPressureResidualPressureFinal StaticPressureP,F,N/AThis building has more than 5 risers.

9 See additional AES form of AES forms attached:Quarterly InspectionsI = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA valves Identification valves inspection Alarm Devices (Dry Pipe Systems) Pass = Normal , , Supply Design Information Sign (For Hydraulically Designed Systems) Information Sign(Not Required for System Prior to 2007 Edition of NFPA 13) Department Pipe valves Exterior Reducing Fire Sprinkler AES 3, 2013 PhoneDry PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and MaintenanceQuarterly andAnnual Report2 of 3 Property InformationContractor or Licensed Owner InformationBuilding NameNameAddressJob #CityANNUAL inspection , TESTING, AND Maintenance Include ALL Quarterly Inspections I = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA ed.

10 ReferenceDateComments OnlyP,F, (Freeze Protection) s and Hose Connections* Service Test Required (Send Report to Fire Code Official) If REQUIRED, Enter 'F' until results are returned from Sprinklers If not present = Pass; If present = FailTitle (c) )low Alarm Devices 90 sec. maximum-(Enter Time ) Drain Test (Enter Data on Page 1 of this Form) Water Level Pipe Valve Trip Test (Partial Trip Test is Acceptable) Trip Air Device Air Pressure Alarm Temperature Alarm Air Pressure Maintenance Device Valve Supervisory Preventer Partial * Small hose connections are hose valves and optional hose supplied by the fire sprinkler system. They do not include Class I, II, or IIIstandpipe AES 3, 2013 Dry PipeFire Sprinkler SystemCalifornia Code of Regulations - Title 19 inspection , Testing, and MaintenanceQuarterly andAnnual Report3 of 3 Property InformationContractor or Licensed Owner InformationBuilding NameNameAddressJob #CityANNUAL inspection , TESTING, AND Maintenance Include ALL Quarterly Inspections I = inspection T = Test M = MaintenanceP = Pass F = Fail N/A = Not ApplicableItemDescriptionNFPA 25 CA ed.