FIRE 

EXTINGUISHER MAINTENANCE INSPECTION
CHECKLIST

ACCORD CHECK LIST OF FIRE EXTINGUISHER

To be completed by the Inspector at the time of Inspection

Attach additional sheets, data or calculation as necessary to provide a complete record 
FACTORY INFORMATION
Factory Name:
________________________________________________
Address:
____________________________________________________
Representative Name:
__________________________________________
Designation:_______________________________________________
__
Phone:____________________________Fax:____________________
__
E-mail:_________________________________

INSTALLATION, SERVICE AND TESTING CONTRACTOR INFORMATION

(IF APPLICABLE)

Contractor
Name:______________________________________________
Address:
____________________________________________________
Inspector or Tester Name:
________________________________________
Qualification of Inspector or Tester:
_________________________________
Phone:___________________________Fax:_____________________
__
E-mail:_________________________________
A Contract for Inspection & testing in accordance with NFPA is in effect as of:
__________________The Contract Expires:
________________Frequency of Test: __________________.

WITNESS BY
Company Name:
______________________________________________
Address:
____________________________________________________
Representative Name:
__________________________________________
Designation:
_________________________________________________
Phone:___________________________Fax:
_______________________
E-mail:___________________________________

As per NFPA standard No. 1 1 0, A functional test shall be conducted on every required
Potable Fire Extinguisher at 30-day intervals for a minimum of 30 seconds. Equipment shall
be fully operational for the duration of visual test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having jurisdiction.
MAINTENANCE INSPECTION CHECKLIST
Floor
No Ground Floor, West Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and facing
3 outward
4 Safety seals and tamper indicators not broken or missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable range
7 or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

Floor
No Ground Floor, East Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and facing
3 outward
4 Safety seals and tamper indicators not broken or missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable range
7 or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

MAINTENANCE INSPECTION CHECKLIST

Floor No 1st Floor, West Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and
3 facing outward
Safety seals and tamper indicators not broken or
4 missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable
7 range or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

Floor No 1st Floor, East Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and
3 facing outward
Safety seals and tamper indicators not broken or
4 missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable
7 range or position
 Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

MAINTENANCE INSPECTION CHECKLIST

Floor No 2nd  Floor, West Wing Comments

 S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and
3 facing outward
Safety seals and tamper indicators not broken or
4 missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable
7 range or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

Floor No 2nd  Floor, East Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate
3 legible and facing outward
Safety seals and tamper indicators not
4 broken or missing
Fullness determined by weighing or
5 “hefting”
6 Examination for obvious physical
damage, corrosion, leakage, or
 clogged nozzle
Pressure gauge reading or indicator in
7 the operable range or position
Condition of tires, wheels, carriage,
hose, and nozzle checked (for
8 wheeled units)
9 HMIS label in place

MAINTENANCE INSPECTION CHECKLIST

Floor
No 3rd  Floor, West Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and facing
3 outward
4 Safety seals and tamper indicators not broken or missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable range
7 or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

Floor No 3rd  Floor, East Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and
3 facing outward
Safety seals and tamper indicators not broken or
4 missing
 5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable
7 range or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

MAINTENANCE INSPECTION CHECKLIST

Floor
No 4th  Floor, West Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and facing
3 outward
4 Safety seals and tamper indicators not broken or missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable range
7 or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

Floor No 4th  Floor, East Wing Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and
3 facing outward
 Safety seals and tamper indicators not broken or
4 missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable
7 range or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

MAINTENANCE INSPECTION CHECKLIST

Floor No Utility Building Comments

S/L Description YES NO N/A

1 Location in designated place
2 No obstruction to access or visibility
Operating instructions on nameplate legible and
3 facing outward
Safety seals and tamper indicators not broken or
4 missing
5 Fullness determined by weighing or “hefting”
Examination for obvious physical damage, corrosion,
6 leakage, or clogged nozzle
Pressure gauge reading or indicator in the operable
7 range or position
Condition of tires, wheels, carriage, hose, and nozzle
8 checked (for wheeled units)
9 HMIS label in place

Disclaimer: The list is not all encompassing due to the extensive list of adopted codes. The Inspector
shall documents all fire and life safety violations and corrections when any are discovered
during inspection.
                                                                                                            On behalf of DGM,
                                                                                                      HR, Admin & Compliance
Inspector’s Signature                                                                 Factory Owner’s Signature
Date:                                                                                            Date: