American Canyon Fire Protection District Business Self Inspection Form

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Please correct the field(s) marked in red below:

Occupancy Information:

Date of Inspection:
 *
Business License #:
 *
Business Name:
 *
Business Email:
 *
Mailing Address:
 *
Mailing Address:
Phone #:
 *
Fax #:
Other Business at the same address are:

Owner
 *
Owner
Manager
 *
Manager
Property Owner
 *
Property Owner
Business Hours
 *
Business Hours

Emergency Contacts – After Hours
Contacts will be called in the order listed

Contact #1
 *
Contact #1
Contact #2
 *
Contact #2
Contact #3
 *
Contact #3

This inspection pertains to your suite only and does not include any area in common with other tenants or with the building owner. If any item that is the landlord’s contract responsibility is not in compliance, it must be corrected before submitting the completed inspection.

General Housekeeping:
 *
General Housekeeping:
Yes No N/A
Is your business address clearly visible from the street, on a contrasting background?
Is driveway or alley around the building kept clear for fire apparatus access?
Are all sides of the building, driveway or alley around the building kept clear of weeds and debris?
Are large capacity trash containers kept at least five feet from the building and in the closed position?
Comments:
Exits:
 *
Exits:
Yes No N/A
Are the exits and doors easily recognizable, and unobstructed (are exit signs lit)?
All the exit doors functional? Are doors able to open from the inside without a key and or special knowledge?
Are the exits and hallways free from the storage of combustible materials?
Are doors with self-closing hinges maintained in the closed position (not blocked open)?
Exit Signs:
 *
Exit Signs:
Yes No N/A
If exit signs are installed in your business are they maintained illuminated or self-luminous?
Does the back-up battery work? (Push the test button) The exit sign should illuminate under battery power.
Emergency lighting/Egress Illumination:
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Emergency lighting/Egress Illumination:
Yes No Maybe
If emergency lighting is provided, is it maintained in operable condition?
Is the means of egress in the building illuminated when occupied?
Comments
Electrical:
 *
Electrical:
Yes No N/A
Are all electrical outlets, switches, and junction boxes properly covered with cover plates?
Are all circuit breakers/fuses within your business clearly labeled and in the on position?
Is the area maintained clear at least 30” on all sides of the electrical panel?
Are extension cords used only for temporary use and with portable equipment only?
If multiple items need to be plugged in, is a power strip utilized with a built-in circuit breaker and is the power tap plugged directly into a permanently installed receptacle?
Are all wires and power strips protected from physical damage, kept out of walkways, doorways, and are not run thru holes in walls or ceilings?
Comments
Fire Protection Equipment:
 *
Fire Protection Equipment:
Yes No N/A
Are fire extinguishers provided and accessible (NOT BLOCKED)
Extinguishers must be mounted no higher than 5’ and no lower than 3’ measured from the top of the extinguisher.
Have fire extinguishers been serviced/tagged within the last 12 –months (Date on tag) ___/___/___
Is the pressure gauge of the fire extinguisher(s) in the operable (Green) range?
Comments
Interior:
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Interior:
Yes No N/A
All breaches, missing ceiling tile/holes in the walls or ceiling that could allow fire into the hidden spaces have been repaired or replaced?
No new walls have been added without necessary permits.
Comments
Storage:
 *
Storage:
Yes No N/A
All storage/housekeeping is neat and orderly.
There is no storage in equipment rooms, mechanical rooms, and electrical rooms or under open stairways.
Storage is piled no higher than 2 feet below the ceiling & never more than 12 feet high or no higher than 18 inches below the ceiling in buildings with sprinkler systems.
Flammable liquids are stored only in approved cabinets.
No more than 10 gallons of flammable liquid stored in approved safety cans.
All combustibles are stored at least 3’ away from any heat sources including gas appliances, space heaters, etc.
All vents of heat-producing appliances (heaters, water heaters, clothes dryers, etc.) are in good repair and functioning properly.
Fire Sprinkler Systems:
 *
Fire Sprinkler Systems:
Yes No N/A
The sprinkler system has been tested by a licensed contractor (C-16) at least once in the last 5 years,
You have received documentation from him/her verifying the test.
I have recorded quarterly inspection information on the sheet
The sprinkler system has been inspected at least once in the last year.
Comments
Natural Gas:
 *
Natural Gas:
Yes No N/A
All water heaters have a pressure-relief valve.
All water heaters have a seismic restraint.
All natural-gas appliances have individual gas shut-off valves.
Comments

A “No” response to any of these questions indicates the presence of a fire code violation. Once all hazards identified as having a “No” response are corrected, please sign, date and return this form to the American Canyon Fire Protection District. Always remember to keep a copy of this inspection for your records.


Please consider this inspection form as an official order for compliance with all applicable codes and ordinances of the American Canyon Fire Protection District.
I hereby certify that the above information, to the best of my knowledge is true and correct:
 *
I hereby certify that the above information, to the best of my knowledge is true and correct:
If you wish to decline participation in the Self-Inspection Program and would rather have the Fire District perform the inspection for you, please indicate that in the comment section below. A representative from our office will contact you at a later date for scheduling.
Additional Comments:
  1. To receive a copy of your submission, please fill out your email address below and submit.

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