![](media/image1.png){width="0.8541666666666666in"
height="1.1041666666666667in"}Contractor's Material and Test

Certificate for Aboveground Piping

(Form AS-5)

**[PROCDURE]{.underline}**

Upon completion of work, inspection and tests shall be made by the
contractor's representative and witnessed by the Contracting Officer or
his/her designee. All defects shall be corrected and the system left in
service before contractor's personnel finally leave the job.

A certificate shall be filled out and signed by both a contactor's
representative and the Contracting Officer or his/her designee. Copies
shall be prepared for the authority having jurisdiction, the park unit,
and contractors. It is understood that the signature of the Contracting
Officer or his/her designee in no way prejudices any claim against the
contractor for faulty material, poor workmanship, or failure to comply
with the requirements of the authority having jurisdiction or local
ordinances.

**[PLANS]{.underline}**

Accepted by \[Contracting Officer or his/her designee\]:

(print) (signature)

Park/Office:

Phone No.:

Installation conforms to accepted plans? Yes No

Equipment used is approved? Yes No

If no, explain deviations.

**[INSTRUCTIONS]{.underline}**

Has person in charge of fire equipment been instructed as to location of
control valves and care and maintenance of this new equipment? Yes No

If no, explain.

Have copies of appropriate instructions and care and maintenance charts
been left on premises? Yes No

If no, explain.

**[LOCATION OF SYSTEM RISER]{.underline}**

Riser location:

Piping Supplies building(s): FMSS Asset ID Number:

**[SPRINKLERS]{.underline}**

**Year of Orifice Temperature**

**[Make]{.underline} [Model]{.underline} [Manufacturer]{.underline}
[Size]{.underline} [Quantity]{.underline} [Rating]{.underline}**

  ------------- ---------- -------------- ---------- ---------- ----------
                                                                

                                                                

                                                                

                                                                

                                                                
  ------------- ---------- -------------- ---------- ---------- ----------

**[PIPE FITTINGS]{.underline}**

Pipe conforms to standard

(If no, explain)

Fittings conform to standard

(If no, explain)

**[ALARM VALVE OR FLOW INDICATOR]{.underline}** **Maximum Time to**

**Alarm Device Operate Through Test Pipe**

  ------------------ ------------- ------------- ------------- -------------
  **Type**           **Make**      **Model**     **Minutes**   **Seconds**

                                                               

                                                               
  ------------------ ------------- ------------- ------------- -------------

**[DRY PIPE OPERATING TEST]{.underline}**

**Dry Valve Quick Opening Device (Q.O.D)**

  ----------- ----------- ----------- ---------- ------------- -------------
  **Make**    **Model**   **Serial    **Make**   **Model**     **Serial
                          No.**                                No.**

                                                               
  ----------- ----------- ----------- ---------- ------------- -------------

**Time to Trip Trip Point Time Water Alarm**

**Through Water Air Air Reached Operated**

**Test Pipe\* Pressure Pressure Pressure Test Outlet\* Properly**

<table style="width:100%;">
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<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 10%" />
<col style="width: 11%" />
<col style="width: 13%" />
<col style="width: 9%" />
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</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td><strong>Min.</strong></td>
<td><strong>Sec.</strong></td>
<td><strong>Psi (Bar)</strong></td>
<td><strong>Psi (Bar)</strong></td>
<td><strong>Psi (Bar</strong></td>
<td><strong>Min.</strong></td>
<td><strong>Sec.</strong></td>
<td><strong>Yes</strong></td>
<td><strong>No</strong></td>
</tr>
<tr class="even">
<td><p><strong>Without</strong></p>
<p><strong>Q.O.D</strong></p></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><p><strong>With</strong></p>
<p><strong>Q.O.D</strong></p></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

**comments:**

[**BACKFLOW PREVENTION DEVICE (**Forward Flow Test)]{.underline}

Method of Flow: Main Drain Fire Department Connection Fire Department
Connection By-pass

**\* Test shall deliver designed flow rate for system, including hose
stream, where hydrants or inside hose stations are**

**located downstream of the backflow preventer.**

**[DELUGE AND PRE-ACTION VALVES]{.underline}**

Operation: Pneumatic Electric Hydraulic

Piping supervised: Yes No

Detecting media supervised: Yes No

Is there an accessible facility in each circuit for testing: Yes No

If no, explain.

+-----------+-----------+--------+------+--------+---+-------+-----+
| **Make**  | **Model** | **Does |      | **Does |   | **Ma  |     |
|           |           | each   |      | each   |   | ximum |     |
|           |           | c      |      | c      |   | Time  |     |
|           |           | ircuit |      | ircuit |   | to**  |     |
|           |           | ope    |      | o      |   |       |     |
|           |           | rate** |      | perate |   | **op  |     |
|           |           |        |      | valve  |   | erate |     |
|           |           | *      |      | rele   |   | rele  |     |
|           |           | *super |      | ase?** |   | ase** |     |
|           |           | vision |      |        |   |       |     |
|           |           | loss   |      |        |   |       |     |
|           |           | al     |      |        |   |       |     |
|           |           | arm?** |      |        |   |       |     |
+-----------+-----------+--------+------+--------+---+-------+-----+
|           |           | *      | **   | *      | * | **M   | **  |
|           |           | *Yes** | No** | *Yes** | * | in.** | Sec |
|           |           |        |      |        | N |       | .** |
|           |           |        |      |        | o |       |     |
|           |           |        |      |        | * |       |     |
|           |           |        |      |        | * |       |     |
+-----------+-----------+--------+------+--------+---+-------+-----+
|           |           |        |      |        |   |       |     |
+-----------+-----------+--------+------+--------+---+-------+-----+

**[TEST (description)]{.underline}**

**HYDROSTATIC:** Hydrostatic tests shall be made at not less than 200
psi (13.6 bar) for two hours or 50 psi (3.4 bar)

above static pressure in excess of 150 psi (10.2 bar) for two hours.
Differential dry pipe valve clappers shall be left

open during test to prevent damage. All aboveground piping leakage shall
be stopped.

**PNEUMATIC:** Establish 40 psi (2.7 bar) air pressure and measure drop,
which shall not exceed 11/2 psi (0.1 bar) in

24 hours. Test pressure tanks at normal water level and air pressure and
measure air pressure drop, which shall not

exceed 11/2 psi (0.1 bar) in 24 hours.

**\*Measure from time inspector's test pipe is opened**

**[TEST]{.underline}**

All piping hydrostatically tested at psi (bar) for hrs.

Dry piping pneumatically tested: Yes No

Equipment operates properly: Yes No

If no, state reason.

Drain test---Reading of gauge located near water supply test pipe:
Static pressure: psi (bar)

Drain test---Residual pressure with valve in test pipe open wide: psi
(bar)

Underground mains and lead-in connections to system risers flushed
before connections made to sprinkler piping

(verified by review of completed copy of NPS Form AS-4?) Yes No Other

Flushed by installer of underground sprinkler piping: Yes No Other

If other, explain.

**[BLANK TESTING GASKETS]{.underline}**

Number used Locations Number removed

**[CUTOUTS (discs)]{.underline}**

Do you certify that you have a control feature to ensure that all
cutouts (discs) are retrieved? Yes No

**[Welding]{.underline}**

Welded piping: Yes No

If yes, **Yes No**

Do you certify as the sprinkler contractor that welding procedures
comply with the

requirements of at least AWS D10.9, Level AR-3?

Do you certify that the welding was performed by welders qualified in
compliance

with the requirements of at least AWS D10.9, Level AR-3?

Do you certify that welding was carried out in compliance with a
documented

quality control procedure to insure that all discs are retrieved, that
openings in

piping are smooth, that slag and other welding residue are removed, and
that

the internal diameters of piping are not penetrated?

**[HYDRAULIC DATA NAMEPLATE]{.underline}**

Nameplate provided? Yes No

If no, explain.

Date system left in service with all control valves open:

**Remarks:**

**[SIGNATURES]{.underline}**

Sprinkler Contractor Business Name:

Address:

Phone No.: License or Certificate Number:

Name of Technician: Signature:

Regional Structural Fire Management Officer (of his designee):

Date: