CAN/ULC-S536-04 Fire Alarm Annual Inspection Test Form
| |Annual Smoke/CO/FE Inspection Report |
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|1621 St Georges Street, Orleans, Ontario | |
|(613) 277-0390 | |
|Creating | |
| |Date of Service |Last Service Date |Work Order Number |
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| |Name: |
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| |Address: |
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| |City: |Postal Code: |Phone: | |
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| |Email Address |Cell: | |
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|Fire & Life Safety Systems |( |Tested By |Initial |Comments |
|Smoke/CO/Heats/Manual Stations | | | | |
|Fire Extinguishers Test Report | | | | |
|Kitchen Suppression System | | | | |
|Emergency Lighting System | | | | |
|Device |Description |Type |Model No. |
|SA/P |Photo-Electric Smoke Alarm | | |
|SA/I |Ionization Smoke Alarm | | |
|HD |Heat Detector | | |
|FHD |FHD | | |
|MPS |Manual Station | | |
|SA/CO |Smoke Alarm Carbon Monoxide Detector combo | | |
|FE5 |5 lb Fire Extinguisher | | |
|FE10 |10 lb Fire Extinguisher | | |
|FEK |Kitchen Fire Extinguisher | | |
|KSS |Kitchen Suppression System | | |
|ELS |Emergency Lighting System | | |
INDIVIDUAL DEVICE RECORD
|Column Legend |
|A |Correctly installed | | |
|B |Unit requires service, repair, missing, or cleaning | | |
|C |Alarm operation confirmed Smoke or Test Button | | |
“(” Yes - Acceptable “X” No – Unacceptable (Explain NO answers in Remarks) “-” Not Applicable
|Location |Device |A |B |C |Remarks |
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Annual Extinguisher Report
|Column Legend |
|Mfg Date |Date of Manufacture (year only) |Major Service Performed |
|Svc Date |Last Major Service Date (year only) | |
| | |R |Recharge |
| | |M |Internal Maintenance |
| | |H |Hydrostatic Test |
“(” Acceptable “X” Not Acceptable (Explain “NO” answers in remarks).
|EXTINGUISHERS |
|LOCATION |SIZE / TYPE |SERIAL # |Mfg |Svc |R |( |REMARKS |
| | | |Date |Date |M | | |
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|Comments/Notations: |
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|The information on this form (and in the documents attached here-to) attest to the fact that the equipment listed here-in was tested/inspected in conformance by a |
|qualified technician. The equipment was left in an operational condition except as noted in the spaces marked “comments”. This document has been provided to the |
|Home/Building owner who has acknowledged receipt of same below. |
| |19-997383 | | |
|Technician Signature |CFAA Certification Number |Date |Owner/Agent Signature |
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