Gilford, Lancaster, Nashua, Hudson & Newington, NH

Telephone: (603) 293-7531 Fax: (603) 589-2051

www.getfireprotection.com

TRI STATE FIRE PROTECTION, LLC Remit to:

26 Hampshire Drive Hudson, NH 03051

KITCHEN SYSTEM INSPECTION Page 1 of 2

Inspected to the current version of NFPA 17A & 96

WORK ORDER #: DATE: CUSTOMER ID:

BILL TO: SHIP TO: Phone: Contact: Email: Phone:

CUST. PO#

Model # and Type: _________________ Annual

Semi-annual

Recharge

Installation

Renovation

Hydrostatic test date: Cylinder 1:________________ Cylinder 2:_________________ Cylinder 3:_________________

Amerex

Ansul

Buckeye

Kidde

Protex

Pyro-Chem

Range Guard

Other

Location of System: ________________ Single

Double

Triple

Other

Last Cartridge Test: ________________ Year Replaced: _________________ Grease Accumulation: Normal Heavy

Fusible Links: _________ 360 degree _________ 500 degree _________ Other

Fire Extinguishers Last Inspected by: _____________________________ Date: ____________________________________ Yes No N/A Yes No N/A 1 Interlocked with building fire alarm 22 Manual and remote set seals in place 2 System fully charged 23 System operational and armed 3 All seals intact 24 Slave system operational and armed 4 All appl. properly covered 25 Fan warning sign on hood 5 Duct & plenum nozzles covered 26 K Class extinguisher in cooking area 6 Checked positioning of all nozzles 27 Proper ABC ext. for other areas 7 Hood/duct penetrations sealed 28 Fire extinguisher properly serviced 8 Pressure gauge in proper range 29 Explained operation of system 9 Inspect cylinder and mount 30 Monthly inspection documented 10 Operated system from terminal link 31 Explained operation of fire extinguisher 11 Checked cable and link position 32 Certification tag on system 12 Replaced fusible links 33 System installed per U.L. 300 13 Checked operation of manual release 34 Owner’s manual on site 14 Check operation of micro-switch 35 System cartridge reinstalled 15 Inspect gas valve Size: ______ 36 Safety pins removed 16 Piping/conduit securely bracketed 37 Checked cartridge weight 17 Nozzles cleaned 18 Proper nozzle caps/covers in place 19 Clearance flame to filters 20 Separation between fryers and flame 21 Exhaust fan in operating order

THIS SYSTEM PASSED NON-COMPLIANT Note: Improperly maintained exhaust systems and/or non-compliant fire systems may fail to suppress a fire.

Gilford, Lancaster, Nashua & Newington, NH Telephone: (603) 293-7531

Fax: (603) 589-2051 www.getfireprotection.com

TRI STATE FIRE PROTECTION, LLC Remit to:

84 Lake Street Nashua, NH 03060

KITCHEN SYSTEM INSPECTION Page 2 of 2

Inspected to the current version of NFPA 17A & 96

Non-compliance:

For non-compliant systems, please call 603-293-7531 and ask for the Suppression Department.

WORK ORDER #: DATE: CUSTOMER ID: QTY PART DESCRIPTION PRICE AMOUNT

SUB TOTAL TAX TOTAL

TECHNICIAN’S REMARKS:

THIS IS NOT AN INVOICE BILLING ADDRESS CONFIRMED

CUSTOMER’S SIGNATURE - DATE TECHNICIAN’S SIGNATURE – DATE

702470027020702170227019202820172004

SEMI ANNUAL FIRE SUPPRESSION INSPECTIONADD'L FIRE SUPPRESSION SYSTEM CYLINDER INSPECTIONREPLACE FUSIBLE LINKS - INCLUDES LABORRUBBER NOZZLE CAPS REPLACED - INCLUDES LABORMETAL NOZZLE CAPS REPLACED - INCLUDES LABORREPLACE SYSTEM CO2 ACTIVATION CARTRIDGE - 12/16 OZKITCHEN SYSTEM SERVICE CALLPORTABLE EXT. ANNUAL INSPECTION W/TAGS AND SEALSDISCHARGE ASSURANCE PLAN (12 MONTHS)