Confidence Test Report Form - Clean Agent Or Co2system - Seattle Fire Department
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1
2
3
4This is a Federal Building
Seattle Fire Department
Confidence Testing Company
LOGO and Info goes here
Confidence Test Report (use one form per sys.)
Address
206-386-1448 Confidence Testing Officer
206-615-1068 (fax)
Phone
Here
206-233-7219 Red Tag Hotline
C
A
CO
S
LEAN
GENT OR
YSTEM
2
Status Given
C
A
CO
LEAN
GENT
2
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:_________________________
Annual
Test Frequency
:
System Make:
______________________
System Model:
_____________________
System Identification No.
________________
System Location:
_____________________
SFD ID No. _________________
(Call 386-1448 for this No.)
Monitoring Company
Yes
No
Central station monitoring?
Yes
No
Name ________________________________
Monitoring Required?
? Yes No
D
F
List items that were not corrected at the time of the confidence test. Use
EFICIENCIES
OUND
the Deficiencies section or attach itemized sheet
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
ADMINISTRATIVE RULE 9.02.09
ALL DEFICIENCIES RECORDED ON THIS REPORT SHALL BE CORRECTED WITHIN 30 DAYS OF THE TEST DATE
Clean Agent or CO
9-2012 Ver.1.3
2
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