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Inspection; Testing, and Maintenance Cover Sheet
NFPA25 as amended by CCR, Title 19
Name: Hoag Memorial Hospital
Address. 1 Hoag Dr. Construction Type: Type I -A
City: Newport Beach
ZIP: 92658
Contact: Erik Lidecis
Telephone:
Name:
Address:
City:
State:
Telephone:
CA License#:
Job #:
Performed by:
(949)764-6574
TO -Signal Integration
28110 Ave Stanford
Santa Clarita
CA
(818) 566-8558
758792
019676
Luis Castellanos
Occupancy/Use:
No. Stones:
Year Constructed:
11
Copy sent to:
Owner
❑ Fire AHJ
j_ Contractor
Date:
Date:
Date:
09/18/20
NOTES:
1) For specific inspection, testing, and maintenance
requirements and information, see NFPA 25, 2011
Edition as amended by California Code of Regulations,
Title 19, §901 to §906.
2) Inspection items may be performed by the owner in
accordance with California Code of Regulations, Title 19,
§904.1(a)
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Forms Included with this Report NFPA 25 Number of Forms
Chapter
❑ Standpipe and Hose System
• Private Water Supply System
❑ Fire Pump
❑ Water Storage Tank
❑ Water Spray System
❑ Foam Water Sprinkler System
6
7
8
9
10
11
❑ Water Mist System 12
❑ Concerns that are not deficiencies (i.e. Non-Sprinklered Areas)
0
1
0
0
0
0
0
6 WV'
� •s, k�-,r,�il•.
1 11
❑
n
n
n
u
❑ Yes
11 I
n
® No
AES 1
Septernber 3.2013
'S
Private Fire
Service Main
Property Information
California Code of Regulations - Title 19
Inspection, Testing, and Maintenance
[Building Name
Address
Hoag Memorial Hospital
1 Hoag Dr.
"R6 MI{ s
Quarterly and
Annual Report
1 of 2
Contractor or Licensed Owner Information
Name
TRI-SIGNAL INTEGRATION
Address
28110 Ave Stanford
City Santa Clarita St. CA Zip 91355
City
Newport Beach, CA 92658
License # 758792
Phone
(818) 566-8558
Contact Person
Erik Lidecis
0 SFM
Job #
019676
Phone
(949)764-6574
CSLB
Misc.
Quarterly Inspections
I = Inspection T = Test M = Maintenance
P = Pass F = Fail N/A = Not Applicable
1.1
I
Control Valves — Identification Sign
13.3.1
NIA
P
--i
1.2
I
Control Valves —Inspection
13.3.2
1.3
I
Hose Houses
7.2.2.7
N/A
1.4
I
Fire Department Connections
13.7
N/A
1.5
I
Pressure Reducing Valves
13.5.1.1
N/A
1.6
I
Backftow Preventers
13.6.1
N/A
1.7
I
Supervisory Devices
13.3.3.5.1
N/A
1.8
I
Monitor Nozzles
7.2.2.6
NIA
1.9
I
ANNUAL INSPECTION,
Include
= Ins. :.lion T = Test M = Maintenance
Hydrants
(Dry Barrel and Wall)
TESTING,
ALL Quarterly
7.2.2.4
Table 7.2.2.4
AND MAINTENANCE
Inspections
P =
Pass F = Fail N/A = Not Applicable
NIA
1.10
I
Hydrants
(Wet Barrel)
7.2.2.5
Table 7.2.2.5
9/18/20
P
1.11
I
Mainline Strainers
7
Tablee 71. 7.2.2.3
N/A
1.12
I
Piping (Exposed)
7.2.2.1
Table 7.2.2.1.2
9/18/20
P
1.13
I
Piping (Underground)
7.3.1
N/A
1.14
i
Hose
NFPA 1962
N/A
2.1
T
Control Valve - Position
13.3.3.1
9/18/20
P
2.2
T
Control Valve - Operation
13.3.3
9/18/20
F
2.3
T
Monitor Nozzles
7.3.3
N/A
2.4
T
Hydrants - Flush
7.3.2
9/18/20
P
2.5
T
Supervisory Devices
13.3.3.5
N/A
2.6
T
Backtow Preventer Assemblies
13.6.2
N/A
2 7
T
Pressure Reducing Valve
(Partia! Flow Test)
13.5.1.3
N/A
3.1
M
Control Valves
13.3.4
9/18/20
P
3.2
M
Mainline Strainers
7.2.2.3
N/A
Form AES 4
Sept. 3, 2013
Private Fire
Service Main
California Code of Regulations -Title 19
Inspection, Testing, and Maintenance
Property Information
Building Name
Hoag Memorial Hospital
Quarterly and
Annual Report
2 of 2
Contractor or Licensed Owner Information
Name
TRI-SIGNAL INTEGRATION
3.3 M Hose Houses
3.4
M
Hydrants
ANNUAL INSPECTION, TESTING, AND MAINTENANCE
Include ALL. Quarterly Inspections
7.2.2.7
Table 7.2.2.7
7.4.2
P = Pass F = NIA = Not A. •licable
09/18/20
3.5
Monitor Nozzles
7.4.3
3.6
M
Obstruction Investigation required
(If °Yes". see Deficiencies and Comments Section
for Results.)
14.3
3.7
System Retumed to Service
4.5.3
15.7
09/18/20
El Yes
Zj No
*Yes
C..i No
N/A
P
N/A
N/A
P
D = Deficiency
Item
C
Date
= Comment
Riser
D
(indicate
C
type )
Deficiencies and Comments
ihdicare all equipment devices and parts that were repaired or replaced
2.2
09/18/20
J
1
Building 24 and south parking - Main water control valve is covered with asphalt
1
0 Check here if additional Deficiencies and Comments are listed on Form AES9 Number attached:
Li See Correction Form AES 10 for corrected deficiencies. Number attached
1 hereby certify that the fire protection equipment listed above has been fully inspected, tested, and maintained on this date by
the company indicated above, in accordance with CCR, rile 19, Sections 901 to 906 and that the equipment is fully operable
except as noted in the "Deficiencies and Comments" section of this form.
Date
Check box if Annual Inspection,
ug',S'�...,[
09/18/20
Testing & Maintenance Items
are Completed in the Indicated
Quarter
..
Print Name
Luis Castellanos
--1
Signature
/Ax
TRI•SIGNAL
INTEGRATION, INC.
fluid FIr
Int Test Repolrt
Owners Name: Hoag Memorial Hospital
Address: 1 Hoag Dr.
Attn: Erik Lidecis
Fire Hydrants Annual Test
1. Caps missing?
2. Threads damaged?
3. Outlets operate freely
4. Obstructions - visible or accessible
5. Outlets 14" to 24" above grade
6. Flow test required
X
YES
YES
YES
YES
YES
YES
Date: September 18, 2020
Phone: (949)764-6574
NO
NO
NO
NO
NO
NO
NOTES:
LOC/#: By building 24 & 25 STAT PSI: 60 GPM FULLFLOW: 1190 RES PSI: 55
LOC/#: By building 24
STAT PSI: 60
GPM FULLFLOW: 1130
RES PSI:
50
LOC/#: By building 18 STAT PSI: 60 GPM FULLFLOW: 1190 RES PSI: 50
LOC/#: Ambulance Exit
STAT PSI: 55
GPM FULLFLOW: 1190
RES PSI:
55
LOCI#: By West tower cafe STAT PSI: 60 GPM FULLFLOW: 1190 RES PSI: 50
LOC/#: South Parking STAT PSI: 60 GPM FULLFLOW: 1190 RES PSI: 50
LOC/#: By building 31 STAT PSI: 55 GPM FULLFLOW: 1130 RES PSI: 55
LOC/#:
STAT PSI: GPM FULLFLOW: RES PSI:
LOC/#:
STAT PSI:
GPM FULLFLOW: RES PSI:
LOCI#:
STAT PSI: GPM FULLFLOW: RES PSI:
This inspection report is not a warranty. but rather a factual diagnostic survey of specifically mandated. vital systemic check points.
Defects noted below have not been repaired and a separate cost estimate shall be provided to owner for authorization to repair.
LOCI#:By building 18 GPM FULLFLOW: 2515 @ 20 PSI
Notes & Deficiencies:
Main Water Valve is covered with asphalt at the hydrant by building 24 and the hvdfeant by south parking
r fRE -Tiz itEp y:. , , FIRE DEA
ON'
Luis Castellanos
qua ��eeauueseA
Tester's Printed Name Tester's Signature
September 18coO?Qg,
Date
28110 Ave Stanford, Santa Clarlta, CA 91355 (818)566-8558
www.Tri-Signal.com
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