23A-041 Service Work Order
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MATERIALS ,14, . I I! 'k:. ' S 6' 06
QTY DESCRIPTION PRICE AMOUNT
"1,, NI FIRE FUSIBLE LINKS // ) - . ? 7 regellk
EQUIPMENT
a RUBBER BLOW OFF CAPS we�a �<9 64 BOSWORTH STREET, WEST SPRINGFIELD, MA 01089 413 - 732 -4590
J MACR 4059 - CT F3 -40258 - VT T2 -406
METAL BLOW OFF CAPS
CUST# `; �, DATE .,c'
RECHARGE K CLASS
PO# PHONE e.-p w) 5y-7 _ er5M y
RECHARGE 5 LB DRY CHEMICAL
NAME . .), ii ;, jrra ,-.�.,.- C;9', :��
RECHARGE 10 LB DRY CHEMICAL
ADDRESS ;/- /r; - 4.- j r-
NEW 5 LB DRY CHEMICAL
NEW 10 LB DRY CHEMICAL CITY , ,f�� - STATE Am ZIP ,asm „
' SOLD BY . COD ACCOUNT
NEW K CLASS
ACTUATION CARTRIDGE LABOR
QTY DESCRIPTION PRICE AMOUNT
NOZZLE EXCHANGE / FIRE SYSTEM INSPECTION e ,
EMERGENCY LIGHT BULB
FIRE EXTINGUISHER INSPECTION If d
"lc� 4
EMERGENCY LIGHT BATTERY e
A 6 YEAR MAINTENANCE
�� �, �� CYLINDER HYDRO TEST I
. HOUR LABOR RATE
SERVICE CALL
EMERGENCY LIGHT INSPECTION
P 41 i c:i 3
ii -" / 1
,
NET 15 DAYS. A FINANCE CHARGE OF 1 1 /2% PER TOTAL MATERIALS 7'
MONTH WILL BE CHARGED ON ALL PAST DUE I
COMMENTS ACCTS. ALL COLLECTIONS, LEGAL FEES, & TOTAL LABOR 1
FINANCE CHARGES WILL BE RESPONSIBILITY OF
CUSTOMER. SUBTOTAL / eft < 4,., 1
' TAX ,%, °4
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SIGNATURE 4 ' � r +' � TOTAL 12',5, 2.2
THANK YOU
As . 9?.O .-1 /1
ALLSTATE
' . FIRE EQUIPMENT Pre - Engineered System Inspection Report
64 BOSWORTH STREET Date of Service: ,ems -, e - .T ime: 'cdi PM
WEST SPRINGFIELD, MA 01089
413 - 732 -4590 877 - 238 -2792 Annual / , ennu I / Recharge / Installation / Renovation (circle one)
1
Customer /Location System Information
Name: -5 Make:
Address: 9 i,,�,.,..,4 `,- , Model: ,,? ,,:
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City, ST, Zip: 4 ,� - . � „, a.,;), Size: ,a
Phone: "'S c 'r Control Head: A, f „,,,,
ne Manager: '2.,.F. Location of system: ,,,,,, ,,, ?M Qom,
Yes No N/A Yes No N/A
1 System interlocked with building fire alarm. 1111 11. - 14 Checked operation of manual release.
2 All tamper seals intact No evidence of tampering. PA SUN 15 Checked operation of microswitch.
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3 All appliances properly covered w/ correct nozzles. Mil 11111 16 Checked operation of gas valve. ECF / ELEC. )
4 Duct(s) & plenum properly covered w/ correct nozzles. 11111 111 111 17 Piping / conduit securely bracket
5 Hood / duct enetrations _
p properly sealed. 18 Nozzles cleaned.
6 Grease accumulation: _excessive _hea QL normal 19 Proper nozzle caps /covers in place. Qty. fiZ
7 Pressure gauge in acceptable range. 111. INI ;4 20 Exhaust fan in operating condition. "V
8 Checked cartridge weight e - 1111 21 System operational & armed. r
9 Cylinder within hydrotest date. Due: ,;„.,70, sr' �1r,� 22 Fan warning sign on hood.
10 Inspected cylinder & mount. 1611 -111 23 K -Class fire extinguisher in cooking area. ,S”
11 Checked operation of detection line. Komi. 24 Personnel instructed on manual operation of system.
12 # of Fusible links: 1 360° d 450° 500° s other( °) 25 Service & certification tag on system.
13 Replaced fusible links. F,,-- 26 System meets U.L. 300 standards.
Cooking Appliances (left to right): e, « , ,, , -
Safety Notice: Non - compliant systems may fail to extinguish/supress a fire. Below are non compliant conditions which require immediate attention. All State
Fire Equipment assumes no responsibility for system performance if these conditions are not corrected and /or verified by an authorized agent of All State Fire
Equipment.
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All State Fire Equipment Agent: >, 1f. ' ', Date: / - /F7'
Customer's Authorized Agent: t/ °'Y`t Date:
MA -CR 4059 CT -F3 -40258 VT -T2 -406 Q
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NFPA Customer Acknowledgement and UL -300 Safety Alert on reverse '1/4 �"� et