Form 9-2012 - Confidence Test Report - Seattle Fire Department printable pdf download

This is a Federal Building 

Seattle Fire Department

Confidence Test Report (use one form per sys.)

206-386-1448 Confidence Testing Officer

206-615-1068 (fax)

206-233-7219 Red Tag Hotline

ANGE

OOD

YSTEM

Status Given



REACCEPTANCE TEST

CONFIDENCE TEST

RED

YELLOW

WHITE

Occupancy Address:

______________________

Occupancy Name:___________________

Responsible Person First

& Last Name:

______________________

Phone Number:

_____________________

Responsible Person

Responsible Party

Address, City, State, Zip:

______________________

E–Mail Address

_____________________

Technician’s Name _______________________

SCP-_______________

SFD Certification No.

(Please Print legibly)

Date of Test:_________________________

Test Frequency:

6 Months

System Make:

______________________

System Model:

_____________________

System Identification No.

________________

System Location:

_____________________

SFD ID No. ________________ (Call 386-1448 for this No.)

The range hood fire suppression system is connected to an FAP with Central station monitoring Yes  No 

If “Yes” Monitoring Company Name ________________________________

? Yes  No 

List items that were not corrected at the time of the confidence test. Use

EFICIENCIES

OUND

the Deficiencies section or attach itemized sheet

Yes 

No 

This kitchen has a Class-K Fire Extinguisher.

(Note: “No” on this item does not produce a “yellow status” for this Range Hood System; however one is required in every

commercial kitchen in the City of Seattle. A Class-K extinguisher shall be installed within 15 days of the date of this test. –

Seattle Fire Marshal )

REPAIRS: All deficiencies have been corrected 

Corrected By: ___________________________

SFD Certification Number: SCP –____________

System Status changed to White (including the tag on the system) 

This certifies that this fire and life safety system has been properly inspected for functional operation in accordance with the

current Seattle Fire Code (SFC), Administrative Rules, and NFPA Standards adopted by the SFC for this system. The

discrepancies found are noted in the report and have been reported to the building Owner/Manager for corrective action.

Signature of Technician

__________________________

Phone #

______________________

Name of Testing Company __________________________________________________________

Building Representative

(signature) ______________________________Date ______________

Print Name and Title_________________________________ Direct Phone # ________________

Building Rep unavailable  Building Rep declined to sign report 

THIS REPORT WILL BE SENT TO THE SEATTLE FIRE DEPARTMENT BY THE TESTING AGENCY IN ACCORDANCE WITH

SEATTLE FIRE CODE ADMINISTRATIVE RULE 9.02.09

ALL DEFICIENCIES RECORDED ON THIS REPORT SHALL BE CORRECTED WITHIN 30 DAYS OF THE TEST DATE

Range Hood System

9-2012 Ver.1.3

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Form 9-2012 - Confidence Test Report - Seattle Fire Department

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