American Fire Protection, Inc.5525 Eastcliff Industrial Loop

Birmingham, AL 35210205-591-9111

Report of Inspection TestingAnnual, Monthly, and Weekly Diesel/Electric Fire Pump Checklist

Location: Date:Inspection#

Yes N/A NoPart 1 Was pump in service when you arrived for inspection?

Suction, discharge, and bypass valves fully opened?Are all control valves accessible?Is the pump room or house enclosure locked securely?Is the pumproom or house enclosure heated (40 degrees F)?Is the pump room or house adequately lighted?Did the fire pump run for a full ( ) minutes?Do packing glands have slight discharge?Is the casing relief valve free of damage?Is the pressure relief valve free of damage?Is the jockey pump operational?Any unusual noises or vibrations?Are all the valves, fittings, and pipe free of leaks?Is the controller power "ON"?Is the hose header control valve closed?Is relief valve drained clogged? -Suction line pressure within acceptable range?Discharge line pressure within acceptable range?Controller power "on" light illuminated?Transfer switch normal power light illuminated?Isolating switch closed?Phase reversal light off?Did relief valve discharge water?Have gauges been changed or calibrated within last (5) years?Are the louvers or in-take ducts clean?Are the proper signage and identication tags in place?Did the alarm panel return back to normal after test?Were all systems left in service?

WRITE PSI BELOW

Part 2 Suction line pressure before test was performed?Discharge line pressure before test was performed?Fire pump starting pressure?Suction line pressure after test was performed?Discharge line pressure after test was performed?

Comments

American Fire Protection, Inc.5525 Eastcliff Industrial Loop

Birmingham, AL 35210205-591-9111

Report of Inspection TestingAnnual, Monthly and Weekly Diesel Fire Pump Checklist

Location: Date:

Yes N/A NoPart 3 Were bearings and valves lubricated?

Is Diesel tank 2/3 full?Is oil level full?Is water level full?Is the water hose condition acceptable?Is the water jacket heater working?Is the antifreeze level full?Does cooling line strainer appear to be clear of debris?Does water jacket piping have any leaks?Are the batteries fully charged?Does the battery charger appear to be working properly?Are the battery terminals clean?Does the solenoid valve appear to be operating correctly?Is the controller selector in the auto position?Are the (2) battery pilot lights on?Are any of battery failure pilot lights on?Are all the alarm pilot lights off?Is the engine running time meter reading?Is the crankcase oil level full?Has the mechanial transmission been checked annually?Has the motor been serviced in last 12 months?

WRITE SECOND

Part 4 How long did it take for engine to crank?How long did it take for engine to reach full speed?

Comments about Diesel Engine:

Inspection # Date:Location Client:

FIRE PUMP

MPG: TYPE:SIZE: Stages:RPM: S/N:IMP. DIA: GPM:DEAD HEAD PSI: PSI:

150% PSI

FIRE PUMP DRIVERELECTRIC DIESEL

MFG: HP:MODEL: AMPS:RPM: VOLTS:HZ: S/N:

COUPLING: 12S

Fire Pump Motor Rotation Checked

Fire Pump Coupling Alignment Checked

JOCKEY PUMP JOCKEY PUMP MOTOR

MFG: MFG:MODEL: HP:CATALOG: RPM:

VOLTS:

Jockey Pump Motor Rotation Checked

Jockey Pump Coupling Alignment Checked

FIRE PUMP CONTROLLER JOCKEY CONTROLLER

MFG: MFG:CATALOG No: MODEL:S/N: S/N:HP: HP:DIAGRAM No: VOLTAGE:AC Input: PHASE:DCVOLT: AMPS:

FIRE PUMP TEST DATA

(205) 591-9990 fax

Birmingham, Alabama 352105525 Eastcliff Industrial LoopAmerican Fire Protection, Inc.

(205) 591-9111 telephone

NUMBER OF MANUAL STARTS

NUMBER OF AUTOMATIC STARTS

PRESSURE SETTINGS:ON OFF

Jockey Pump Pressure

Electric Fire Pump Pressure

Diesel Fire Pump Pressure

YES NOTRANSFER SWITCH

MODEL:S/N:Fire Pump Motor Rotation Checked

YES NOMAIN RELIEF VALVE

MODEL:SIZE:FIELD SET PSI:

OPTIONS/NOTES:

IN ATTENDANCE AT FIRE PUMP TEST:Fire DepartmentAmerican Fire Protection Inc.Insurance Company:Controller MFG Rep:Building Staff Rep:Diesel MFG Rep:Pump MFG Rep:Other:

American Fire Protection, Inc.5525 Eastcliff Industrial LoopBirmingham, Alabama 35210

(205) 591-9111 telephone(205) 591-9990 fax

FIRE PUMP TEST DATA

DATE:

PSI PSI PSIRPM L1 L2 L3 T1 T2 T3 SUCTION DISCHARGE NET #1 #2 #3 #4 #5 #6 GPM

0

MFG:

NOTE:

FIRE PUMP TEST DATA

American Fire Protection, Inc.5525 Eastcliff Industrial LoopBirmingham, Alabama 35210

(205) 591-9111 phone

VOLTS AMPS PITOT TUBE PRESSURES

(205) 591-9990 fax

Inspection # Date:Location Client:

FIRE PUMP

MPG: TYPE:SIZE: Stages:RPM: S/N:IMP. DIA: GPM:DEAD HEAD PSI: PSI:

150% PSI

FIRE PUMP DRIVERELECTRIC DIESEL

MFG: HP:MODEL: AMPS:RPM: VOLTS:HZ: S/N:

COUPLING: 12S

Fire Pump Motor Rotation Checked

Fire Pump Coupling Alignment Checked

JOCKEY PUMP JOCKEY PUMP MOTOR

MFG: MFG:MODEL: HP:CATALOG: RPM:

VOLTS:

Jockey Pump Motor Rotation Checked

Jockey Pump Coupling Alignment Checked

FIRE PUMP CONTROLLER JOCKEY CONTROLLER

MFG: MFG:CATALOG No: MODEL:S/N: S/N:HP: HP:DIAGRAM No: VOLTAGE:AC Input: PHASE:DCVOLT: AMPS:

FIRE PUMP TEST DATA

(205) 591-9990 fax

Birmingham, Alabama 352105525 Eastcliff Industrial LoopAmerican Fire Protection, Inc.

(205) 591-9111 telephone

NUMBER OF MANUAL STARTS

NUMBER OF AUTOMATIC STARTS

PRESSURE SETTINGS:ON OFF

Jockey Pump Pressure

Electric Fire Pump Pressure

Diesel Fire Pump Pressure

YES NOTRANSFER SWITCH

MODEL:S/N:Fire Pump Motor Rotation Checked

YES NOMAIN RELIEF VALVE

MODEL:SIZE:FIELD SET PSI:

OPTIONS/NOTES:

IN ATTENDANCE AT FIRE PUMP TEST:Fire DepartmentAmerican Fire Protection Inc.Insurance Company:Controller MFG Rep:Building Staff Rep:Diesel MFG Rep:Pump MFG Rep:Other:

American Fire Protection, Inc.5525 Eastcliff Industrial LoopBirmingham, Alabama 35210

(205) 591-9111 telephone(205) 591-9990 fax

FIRE PUMP TEST DATA

DATE:

PSI PSI PSIRPM L1 L2 L3 T1 T2 T3 SUCTION DISCHARGE NET #1 #2 #3 #4 #5 #6 GPM

0

MFG:

NOTE:

FIRE PUMP TEST DATA

American Fire Protection, Inc.5525 Eastcliff Industrial LoopBirmingham, Alabama 35210

(205) 591-9111 phone

VOLTS AMPS PITOT TUBE PRESSURES

(205) 591-9990 fax

FORM FOR WEEKLY INSPECTIONS AND TEST OF FIRE PUMPS FOR THE STATE OF ALABAMA HEALTH CARE FACILITIES

Information on this form covers the minimum requirements of NFPA-25-1998 for centrifugal fire pumps. Use of this form, does not relieve the owner of the responsibility to comply with other requirements of NFPA 25-1998 for the Inspection, Testing and Maintenance of Fire Pumps. Owner: Children’s Hospital of Alabama Owner’s Phone Number: 205-638-9103 Owner’s address: 1600 7th Avenue South Property being evaluated: Property address: Date of work: ________________ All responses refer to the current (inspection and test) performed on this date. Note: 1. All questions are to be answered yes, no, or not a applicable. All “no” answers are to be in the comment portion of this form. 2. Inspections are to be performed with water supplies (including fire pumps)in service, unless the impairment procedures of Chapter 11 of NFPA 25 and fire watch procedures of ADPH/TSU are followed.

Part I – Owner’s Section A. Is the fire pump in service? _____Yes _____No _____N/A B. Has the fire pump remained in service since the last inspection? _____Yes _____No _____N/A C. Was the system (of which the fire pump is a part), free from actuation of devices or alarms since the last inspection? _____Yes _____No _____N/A ___________________________________ ____________________________________ Owner or representative (print name) Signature and date Part II – Inspector’s Section A. Inspections – All to be performed weekly. 1. Pump house/room proper temperature at least 70 degrees for diesels without engine heater or 40 degrees for others? _____Yes _____No _____N/A 2. Ventilation louvers free to operate? _____Yes _____No _____N/A 3. Suction, discharge and bypass valves open? _____Yes _____No _____N/A 4. Piping free from leaks? _____Yes _____No _____N/A 5. Suction and system pressure gauges normal? _____Yes _____No _____N/A 6. Record suction _____and discharge _____pressure while not running. 7. Suction reservoir, if provided, full? _____Yes _____No _____N/A B. Electric Motor-Driven Pumps 1. Pump started automatically? _____Yes _____No _____N/A Record starting pressure. _________psi. 2. Pump run for at least 10 minutes? _____Yes _____No _____N/A Record suction ________ and discharge _______ pressure while running. 3. Pump packing gland showing slight discharge? _____Yes _____No _____N/A Have adjusted if necessary by sprinkler contractor. 4. Free from unusual noise or vibration? _____Yes _____No _____N/A 5. Packing boxes, bearing and pump casing free from overheating? _____Yes _____No _____N/A 6. Record time for motor to accelerate to full speed._______ 7. For reduced voltage or reduced current starting, record time controller is on first step. ______ 8. Circulation relief valve flowing water while pump churns? _____Yes _____No _____N/A 9. Pressure relief valves operating with proper pressure downstream while pump is operational? _____Yes _____No _____N/A 10. For automatic stop controllers, record time pump runs after starting.______ 11. All times and pressures in Part B acceptable? _____Yes _____No _____N/A Form Revised 01/10/05

Page 1 of 2

FORM FOR WEEKLY INSPECTIONS AND TEST OF FIRE PUMPS

FOR THE STATE OF ALABAMA HEALTH CARE FACILITIES 12. Electric Motor Driven Pumps a. Controller indicating power on, transfer switch indicating normal situation, and

isolation switch closed? _____Yes _____No _____N/A b. Reverse phase alarm indicator off or normal phase rotation indicator on? _____Yes _____No _____N/A c. Oil level in vertical motor sight normal? _____Yes _____No _____N/A C. Diesel Engine Driven Pumps 1. Fuel tank at least two thirds full? _____Yes _____No _____N/A 2. Controller selector switch in Auto position? _____Yes _____No _____N/A 3. Controller indicating power “on”? _____Yes _____No _____N/A 4. Battery voltage and charger reading normal? _____Yes _____No _____N/A 5. Battery indicators on or failure indicators off? _____Yes _____No _____N/A 6. All alarm indicators off? _____Yes _____No _____N/A 7. Record engine running time meter reading.______ 8. Oil level in right angle gear drive normal? _____Yes _____No _____N/A 9. Crankcase oil level normal? _____Yes _____No _____N/A 10. Cooling water level normal? _____Yes _____No _____N/A 11. Electrolyte level in batteries normal? _____Yes _____No _____N/A 12. Battery terminals free from corrosion? _____Yes _____No _____N/A 13. Water-jacket heater operating? _____Yes _____No _____N/A 14. Pump started automatically? _____Yes _____No _____N/A Record starting pressure. ______psi 15. Pump run for at least 30 minutes? _____Yes _____No _____N/A Record suction _____and discharge _____pressure while running, 16. Pump packing gland showing slight discharge? _____Yes _____No _____N/A 17. Free from unusual noises or vibrations? _____Yes _____No _____N/A 18. Packing boxes, bearing and pump casing free from overheating? _____Yes _____No _____N/A 19. Record time for engine to crank.______ 20. Record time for engine to reach running speed. ______ 21. Engine oil pressure gauge, speed indicator, water and oil temperature indicators all reading normal? _____Yes _____No _____N/A 22. Cooling water flowing from heat exchanger? _____Yes _____No _____N/A 23. Pressure relief valves operating with proper pressure downstream while pump is operational? _____Yes _____No _____N/A 24. All time and pressure in Part C acceptable? _____Yes _____No _____N/A Part III – Comments (Any “No” answers, test failures or other problems found with the fire pump must be explained here.) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Part IV – Inspector’s Information Inspector: Facility: Facility address: I state the information on this form is correct at the time and place of my inspection, and that all equipment was left in Operational condition upon completion of this inspection except as noted in Part III above. Signature of Inspector: _______________________________ Date:____________ State Permit #_ ___ Form Revised 01/10/05 Page 2 of 2

Property Midsouth Date American Fire ProtectionBuilding Number MSLC-1 MSLC-3 MSLC-4Oil ConditionOil LevelBattery ConditionOil PressureR.P.MCharging Volts # 1Charging Volts # 2Heat exchange cooling waterExhaust systerm leak tightWater tempSuction pressure Water Pressure outManual CrankRun TimeFuel LevelPump Control On Pump Control AutoControl ValveAlarm Panel ClearSystem left in Service

Fire Pump Weekly Churn Test