CERTIFICATE

of Inspection

Year : Month : Day : Type and name of ship/unit : Flag : IMO No. : Certificate No. :

Place of service : Classification Society : Enclosed :

We hereby certify that the systems and equipment specified below have been inspected,serviced,refilled.
and tested according to requirement from IMO regulation,SOLAS and manufacturer.
The quantity of equipment and working code enclosed in Service Report back of this page.

- Fixed CO2 System - Medical Oxygen

- Fixed Foam System - Breathing Apparatus

- Foam Test Analist - Escape Sets

- Fixed Suppression System X Fire Hydrant

- Fixed Dry Powder System - Life Jacket

- Portable Fire Extinguisher - Summary of Actions

ZAINUL MA'ARIF
SURYA SEGARA STAMP AND SIGNATURE NAME IN PRINTED NAME
 safety marine
Workshop Labuan Bajo : Kampung Air Kemiri RT01/RW01 Gorontalo, Komodo, Kab. Manggarai Barat Nusa Tenggara Timur - Indonesia

APPROVAL : SAI GLOBAL ISO 9001:2015, 14001:2015, 45001:2018 | www.suryasegara.com

SURVEY AND TEST REPORT HYDRANT & FIRE HOSE

CONDITION OF

Hose No / Hose Nozzle

No Description Code No Location Dia Remarks Recommendation
Mark lenght Ball Butterfly Foam & Pressure Box /
Hose Swivel Gate Valve Connector Foam Tank
Valve Valve Volume Pump Cover
Water Foam Mark/Type

1 FIRE HOSE - Hose 1 Sun Deck 38 mm 20 m OK N/A - OK N/A N/A N/A OK OK N/A N/A - OK

2 FIRE HOSE - Hose 2 Upper Deck AFT 38 mm 20 m OK N/A - OK N/A N/A N/A OK OK N/A N/A - OK

3 FIRE HOSE - Hose 3 MD SS 38 mm 20 m OK N/A - OK N/A N/A N/A OK OK N/A N/A - OK

4 FIRE HOSE - Hose 4 MD PS 38 mm 20 m OK N/A - OK N/A N/A N/A OK OK N/A N/A - OK

5 FIRE HOSE - Hose 5 Fore Deck 38 mm 20 m OK N/A - OK N/A N/A N/A OK OK N/A N/A - OK

6 FIRE HOSE - Hose 6 Swim Platform 38 mm 20 m OK N/A - OK N/A N/A N/A OK OK N/A N/A - OK

7 FIRE HOSE - Hose 7 Lazarette 38 mm 20 m OK N/A - OK N/A N/A N/A OK OK N/A N/A - OK

ZAINUL MA'ARIF
SIGN AND STAMP
 Workshop Labuan Bajo : Kampung Air Kemiri RT01/RW01 Gorontalo, Komodo, Kab. Manggarai Barat Nusa Tenggara Timur - Indonesia
safety marine
APPROVAL : SAI GLOBAL ISO 9001, ABS, LLOYD'S REGISTER, DNV-GL, NKK, BTKP | www.suryasegara.com

SURVEY AND TEST REPORT HYDRANT & FIRE HOSE

CONDITION OF COMMISIONING

Hose No / Hose Nozzle

No Description Code No Location Dia Ball Diameter Pressure Water Remarks Recommendation
Mark lenght Hose Swivel
Butterfly
Gate Valve Connector % open valve nozzle pitot gauge Flow
Valve Valve
Water Foam Mark/Type (mm) (kg/cm2) (LPM)

SIGN AND STAMP