Fire Department______________________________________________________________

Date ___________________  Location___________________________________________

Type of System:   ANSUL R102 ___       KIDDE WET CHEMICAL ___         Other ____

Describe size and type of system_________________________________________________
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Number of appliance nozzles _____             Number of Plenum nozzles______ 
   
Number of Duct Nozzles _____

New System _____          Existing System ______      Existing System with new Additions______

Type of piping ____       Size of piping _____                

Full wet Chemical agent dump test ______

Did any nozzles clog or have reduced flow? ______  

Location of nozzles with problems________________________________________________ 
(describe in detail below)

Retest ____                Did retest pass?______

COMMENTS: ______________________________________________________________
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(When Possible include system plans for review)  

Form Revised: 4/5/01