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Sprinkler sample has been successfully tested within last 10 years? ® Yes 0 No 0 N/A <br /> FIRE DEPARTMENT CONNECTION 0 Yes ® No <br /> INSPECTION COMPLETION <br /> Full walk through performed? d� Yes 0 No 0 N/A <br /> Owner has been advised to protect water filled sprinkler piping from freezing? 0 Yes 0 No 0 N/A <br /> System left in service? 0 Yes 0 No <br /> Inspection tag posted at main valve? <br /> ® Yes 0 No <br /> Informed owner of inspection and testing results and all system deficiencies? 5 Yes 0 No <br /> INSPECTOR'S DECLARATION <br /> By checking here you are certifying, under penalty of perjury,that you area valid agent of your company representing that the <br /> company maintains all the necessary licenses and/or certifications to perform this service for this system in this jurisdiction AND <br /> CU THAT the company has properly inspected this system consistent with state and local standards AND THAT the system has been <br /> properly tagged or labeled and the property owner or responsible person has been notified of the inspection results,the system <br /> status,and any corrective actions. <br /> AUTHORITY SYSTEM INFORMATION <br /> AUTHORITY.REVIEW'REPORT COMMENTS <br />