MONTHLY FIRE PROTECTION INSPECTION FORM

1 Philadelphia Insurance Company Philadelphia Indemnity Insurance Company Maguire Insurance Agency, Inc. MONTHLY fire PROTECTION INSPECTION form Facility Inspector Location Date INSPECTOR INSTRUCTIONS:THE FOLLOWING ITEMS SHOULD BE REGULARLY INSPECTED, TESTED, AND MAINTAINED TO HELP ENSURE COMPLETE AND TOTAL RELIABILITY OF YOUR FACILITIES fire PROTECTION SYSTEMS. COMPLETE THE BELOW CHECKLIST IN ACCORDANCE WITH THE FREQUENCY RECOMMENDED. "NON-BOLDED" RESPONSES SHOULD BE EXPLAINED IN THE ADDITIONAL COMMENTS SECTION. DO NOT COMPLETE A PARTICULAR SECTION UNLESS YOU HAVE PERSONALLY INSPECTED OR TESTED THAT PARTICULAR PIECE OF fire PROTECTION EQUIPMENT. A COPY OF THE INSPECTION form SHOULD BE SENT TO THE DESIGNATED PERSON IN CHARGE FOR NECESSARY ACTION. THE FOLLOWING CHECKLIST IS INTENDED TO PROVIDE OUR CUSTOMERS WITH THE GENERAL INFORMATION NEEDED TO COMPLY WITH MOST LOCAL AND NATIONAL AGENCIES.

2 THIS form SHOULD NOT BE INTENDED AS A SUBSTITUTE FOR ANY ADVICE PROVIDED BY YOUR OCAL AUTHORITY HAVING JURISDICTION. L INSPECT THESE ITEMS AT LEAST MONTHLY WATER SUPPLY AND fire ALARMS (For Buildings with fire Sprinklers) NA__ YesNo YesNo PUBLIC WATER SUPPLY IN SERVICE fire ALARM SYSTEM OPERATIONAL PUBLIC WATER PRESSURE PSI CHANGE FROM PREVIOUS MONTH CENTRAL STATION RECEIVED ALL SPRINKLER WATERFLOW AND TAMPER ALARMS 2 IN. DRAIN TEST PERFORMED fire DEPARTMENT CONNECTION ACCESSIBLE DID WATER MOTOR GONG OPERATE fire DEPARTMENT CAPS IN PLACE INSPECTORS TEST CONNECTIONS FLOWED CLEAR PUBLIC fire HYDRANTS ACCESSIBLE GENERAL COMMENTS: SPRINKLERS / NA ___ YesNo YesNo STOCK MORE THAN 18 IN.

3 FROM SPRINKLER HEADS SPRINKLER HEADS OR PIPING CORRODED SPRINKLER HEADS FREE OF PAINT, DUST OR RESIDUE SPRINKLER HEADS GREATER THAN 50 YEARS OLD ANY HANGING ITEMS ON PIPING OR HEADS ANY HEADS DISCONNECTED OR NEEDED SPRINKLER HEADS UNOBSTRUCTED BY PARTITIONS SPARE SPRINKLER HEADS AVAILABLE GENERAL COMMENTS: fire PUMP & TANK / RESERVOIR (IF APPLICABLE) NA____ YesNo YesNo fire PUMP AUTOMATICALLY STARTED BY PRESSURE DROP: DIESEL: (WEEKLY) ELECTRIC: ( MONTHLY ) BATTERIES PROPERLY CHARGED AND FREE OF CORROSION PUMP RUN FOR MINIMAL TIME: DIESEL PUMP (30 MIN.) ELEC. PUMP (10 MIN.) TANK / RESERVOIR HEATING SYSTEM WORKING PROPERLY PACKING COOL DURING OPERATION TANK/ RESERVOIR FULL OR WAS IT OVERFLOWED PUMP ROOM HEATED & VENTILATED TANK LEVEL INDICATOR OPERATIONAL DIESEL FUEL TANK AT LEAST 2/3 FULL RESERVOIR SCREEN CLEANED FROM DEBRIS GENERAL COMMENTS: DRY PIPE, PREACTION, DELUGE (IF APPLICABLE) NA___ Rm.

4 Rm. No. 2 Rm. No. 3 Rm. No. 4 Rm. No. 5 Rm. No. 6 Rm. No. 7 Rm. No. 8 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No VALVE RM. HEATED AIR PRESS. PSI PSI PSI PSI PSI PSI PSI PSI H2o PRESS. PSI PSI PSI PSI PSI PSI PSI PSI GENERAL COMMENTS: Page 2 of 2 MANUAL PROTECTION YesNo YesNo ADEQUATE NUMBER OF fire EXTINGUISHERS MANUAL PULL STATIONS TESTED PERIODICALLY PROPER EXTINGUISHERS FOR OCCUPANCY INSIDE HOSES ACCESSIBLE EXTINGUISHERS PROPERLY CHARGED INSIDE HOSES IN GOOD CONDITION EXTINGUISHERS PROPERLY LOCATED AND PLACED (HUNG ON SUPPORTS) PRIVATE YARD HYDRANTS ACCESSIBLE AND IN GOOD CONDITION GENERAL COMMENTS: SPECIAL EXTINGUISHING SYSTEMS (IF APPLICABLE) YesNo YesNo SPECIAL EXTINGUISHING SYSTEM IN SERVICE MANUAL ACTUATORS UNOBSTRUCTED DETECTION DEVICES FOR SYSTEM IN SERVICE SYSTEM IS SERVICED BY CERTIFIED CONTRACTOR GENERAL COMMENTS.

5 fire DOORS, fire WALLS YesNo YesNo fire DOORS WELL MAINTAINED COMBUSTIBLE STORAGE AT LEAST 3 FT. FROM fire DOOR fire DOORS FREE FROM OBSTRUCTIONS OR BLOCKAGE fire DOORS PROVIDED WITH PERIODIC MAINTENANCE AND DROP TESTING PROGRAM fire DOOR ARRANGED FOR AUTOMATIC CLOSING HORIZONTAL PENETRATIONS IN fire WALLS PROPERLY SEALED FUSIBLE LINKS FREE FROM PAINT fire WALL IN GOOD STRUCTURAL CONDITION GENERAL COMMENTS: GENERAL CONDITIONS/ SPECIAL HAZARDS YesNo YesNo GOOD HOUSEKEEPING NOTED THROUGHOUT MECHANICAL VENTILATION SYSTEMS OPERATING MINIMAL AISLE STORAGE NOTED IN WHSE. AREAS AEROSOLS KEPT IN METAL CABINETS SMOKING REGULATIONS ENFORCED WITH SIGNS POSTED THROUGHOUT COMPRESSED CYLINDERS PROPERLY STORED AND CHAINED STORAGE SKIDDED OFF FLOOR IDLE PALLET STORAGE BELOW 6 FT. STORAGE WELL ARRANGED TO PREVENT COLLAPSE ELECTRICAL EQUIPMENT IN GOOD CONDITION COMBUSTIBLE WASTE REMOVED PROMPTLY HEATING SYSTEM IN GOOD CONDITION COMBUSTIBLES COMPLETELY REMOVED FROM COMPUTER /ELECTRICAL/MECHANICAL ROOMS PROCESS FUEL-FIRED EQUIPMENT IN GOOD CONDITION DUST/LINT OR OILY DEPOSITS REMOVED FROM CEILINGS.

6 BEAMS OR EQUIPMENT OUTSIDE YARD STORAGE ADEQUATELY SEPARATED FROM BUILDING FLAMMABLE LIQUID DISPENSING CONTAINERS PROPERLY GROUNDED ADEQUATE PROTECTION AGAINST THEFT AND VANDALISM FLAMMABLE LIQUID DISPENSING CONTAINERS PROVIDED WITH SAFETY RELIEF BUNGS BUILDING ROOF CONSTRUCTION IN GOOD CONDITION FLAMMABLE LIQUID DISPENSING CONTAINERS PROVIDED WITH SELF CLOSING FAUCETS BUILDING ROOF FREE FROM PONDING OR LEAKAGE FLAMMABLE LIQUIDS KEPT IN METAL CABINETS OR PROPERLY DESIGNED ROOM DOMESTIC VALVES AND PIPES PROPERLY LABELED AND TAGGED GENERAL COMMENTS: ADDITIONAL COMMENTS AND RECOMMENDATIONS SAMPLE ONLY: THIS form OR SIMILAR form MAY BE REDEVELOPED TO FIT YOUR COMPANY'S SPECIFIC NEEDS. ITEMS THAT DO NOT APPLY CAN BE OMITTED. OTHER ITEMS CAN BE EXPANDED OR NEW ITEMS CAN BE ADDED AS DESIRED. If YOUR LOCATION IS SPRINKLERED, USE THIS form IN CONJUNCTION WITH THE SPRINKLER CONTROL VALVE INSPECTION form .

7 AFTER COMPLETING THE INSPECTION , ONE COPY OF THE form SHOULD BE KEPT ON FILE FOR FUTURE REVIEW, AND ANOTHER COPY SHOULD BE FORWARDED TO MANAGEMENT. MANAGEMENT SHOULD REVIEW form AND TAKE CORRECTIVE ACTION ON ALL NOTED DEFICIENCIES. The information and suggestions presented by Philadelphia Indemnity Insurance Companies in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

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