‘Town of East Hampton Fire Marshals Office 300 Pantigo Place, Suite 111, East Hampton NY 11937 Telephone 631-329-3473 Fax 631-329-9403 KITCHEN HOOD FIRE SUPPRESSION SYSTEMS INSPECTION & MAINTENANCE REPORT Occupancy Name Date Address Hamlet If there are multiple hood systems, use separate forms and identify each system. Identify Hood System Manufacturer of Equipment: AMEREXO ANSULO FSI. KIDDEO PROTEXO PYRO-CHEMO RANGEGUARDO OTHERO. Model: Type: Date of last service: ro 1. System is interconnected with building fire alarm system YesO NoO WAQ 2. Suppression systems discharged sees Yes NoO N/AQ 3. Alll seals intact, no evidence of tampering, Yes NoO NAG 4. All appliances properly covered w/orrect nozzles Yes NoO WAQ 5. Check positioning of all nozzles , ves YesO NoO NAD 6, Duct & plenum covered wicorrect nozzles YesO NoO NAD 7. Hood/duct penetrations sealed .. YeO NoO WAD 8. Grease accumulation: Light 0 Mod. Bea 9. Pressure gauge in proper range 7 10. Checked cartridge weight .......... 11. Cylinder due for hydrostatic test 12, Six year Maintenance 13. Inspect cylinder and mount » YesO NoO WA YesO NoO NAO Yes NoO NAD Date due . YesO NoO NWAQ YesO NoO NAO 14. Operated system from terminal fink eet YesO NoO WAQ 15. Checked travel of cable and link position YesO NoO WAQ 16. Fusible links ..3600 4500 sooo 17. Replaced fusible links, manufacturer date............. - Yes NoO N/AD Man, date 18. Checked and cleaned fusible links YesO NoO NAO 19. Checked operation of manual release .................. YesO NoO NAO 20. Checked operation of micro-switch YesO NoO NAO 21. Checked operation of auto-gas & electric shut-off... YesO NoO NAO Fuel types present: NaturalGasO LPGO Elect. Solid fuel 0 22. Piping/conduit securely bracketed «......-.:sscssesniwee Yes NoO NAD 23. Nozzles cleaned strc ses YesO NoO WAG 24. Proper nozzle caps/covers in place : . YesO NoO WAG 25, Proper clearance between flame & filters . Yes NoO NAG 26. Proper 16” separation between fiyers and open flame........... Yes) NoO NAD od Sipyreion ystems 1.282018 Page 1 snaos27. Exhaust fan in operating order ........ YesO NoO N/A 28. Remote manual release seals in place ....... Yes NoO NAG 29. System cartridge replacedi/safety pins removed ._. Yes NoO NAG 30. System operational and armed ,........ anes YesO NoO N/AQ 31, Slave system operational and armed Asse ssi Yes NoO NAQ 32, Fan warning sign on hood .......seesvssesessssterssvsioe YesO NoO WAO 33. K class fire extinguisher in cooking area » Yes NoO NAO 34, 2A water type or wet chemical extinguisher for solid fuel...... Yes 0 NoO) N/A 35. Water hose in area of solid fuel appliances ......... a YesO NoO NAO 36. Proper ABC fire extinguisher for other areas Yes NoO NAO 37. Fire extinguishers properly serviced ..........0cccseene Yes NoO NAD 38. Personnel instructed in manual operation of system Yes NoO NAO 39, Personnel instructed on required monthly inspection of system Yes NoO N/A 40. Personnel instructed on use of fire extinguishers ........ YesO NoO NAO 41. Service and certification tag on system YesO NoO WAQ 42, System installed per U.L. 300 standard ........ soe Yes NoO WAG 43, System meets manufacturers listing ..........+0.00.0 Yes NoO NAQ 4, System meets N.F-P.A. standards Yes NoO NAD COOKING APPLIANCES UNDER HOOD (LEFT TO RIGHT) NOTE: A non-compliant system may fail to extinguish a fire Comments: Service Service Company. ‘Technician Co. Address Phone. I certify that this inspection and service has been conducted properly and all of the above statements are true and correct to the best of my knowledge. Any false statement herein is punishable as a misdemeanor pursuant to 210.45 NYS Penal Law. Date: /__ 200. Signature of Service Technician ood Suppression Systems 128.2003 Page 2 sme