COMMISSIONING CHECKLIST

(Form No. F-2020042)

2024-JAN-22 REV. 01 PAGE 1

COMMISSIONING CHECKLIST (Complete one checklist per machine - click submit to attach to email)

Contacts Dealer / bill-to information Job site information Authorized ANSUL® distributor
Name
Address
City
State/Province
Zip/Postal code
Country
Contact name
Contact email
Contact phone

EQUIPMENT INFORMATION (per Machine)

Equipment description Customer equipment ID No. Equipment serial No.

ANSUL® Fire Suppression System information

CHECKFIRE 210
Interface Control CHECKFIRE 210
Tank type/size Tank serial No. Module – serial No. Display Module – serial No.

ANSUL® Fire Suppression System test report per machine

1. Suppression hardware Yes No

a) Burst Disc clean and free of damage
b) LVS Agent Tanks filled with appropriate amount of LVS Agent
c) Labels and Nameplate legible and in good condition
d) Distribution hose blown clear and free of debris
e) All distribution hose, fittings, and nozzles properly connected and secure
f) Distribution nozzles properly aimed and blow off caps in place and secure
g) Expellant Gas Cartridge stamped weight - record weight:
Expellant Gas Cartridge actual weight - record weight:
h) Expellant Gas Cartridge guages in GREEN (if applicable, 23 ft3 (0.65 m3) and 55 ft3 (1.56 m3))
i) Expellant Gas Cartridges installed and secured in brackets
j) Electric-Pneumatic Actuator(s) inspected, lubricated and in place
Section 1 Comments

One Stanton Street | Marinette, WI 54143-2542, USA | +1-715-735-7411 | www.ansul.com

© 2024 Johnson Controls. All rights reserved. All specifications and other information shown were
current as of document revision date and are subject to change without notice. | Form No. F-2020042-01
COMMISSIONING CHECKLIST
(Form No. F-2020042)
PAGE 2 REV. 01 2024-JAN-22

ANSUL® Fire Suppression system test report per machine (Continued)

2. CHECKFIRE 210 detection and actuation Yes No

a) Verify CHECKFIRE 210 ICM and Display Module are securely mounted
b) Inspect ICM cable connections for proper connection
c) Inspect all cables and routing for proper connection
d) Labels and Nameplates legible and in good condition
Section 2 Comments:

Job site
Equipment description
Cust. equipment ID No.

3. C
 HECKFIRE 210 operational test
Complete Section 6 – Test and Place in Service in the CHECKFIRE 210 System
Manual (A16381NWJ9) Yes No
a) Vehicle Power operation verified
b) Internal Battery Power operation verified
c) Isolate Mode tested and verified
d) Detection Circuit #1 tested (Supervisory and Activation)
e) Detection Circuit #2 tested [if used] (Supervisory and Activation)
f) T
 ime Delays tested (Factory default: TD1 and TD2 = 10 sec.)
Note: If default ‘Time delays‘ are changed, indicate TD settings below:
TD1 in sec. TD2 in sec.
g) T
 ime Delay Restart tested (Factory default: 1 restart)
Note: If default ‘Restarts‘ are changed to ‘Unlimited’, indicate Yes below:
Unlimited voids FM Approval Unlimited Yes:
h) Release Circuit tested (Supervisory and Activation)
i) R
 elay function tested (Factory default: Rly 1 – Alarm, Rly 2 – Shutdown)
Note: If default ‘Relay Settings‘ are changed, indicate below:
RLY 1: RLY 2:
j) Manual Actuation at “Push to Activate Button“ tested
k) Manual Actuation at Electric Manual Actuator(s) tested
l) Above tests with both External (machine) and Internal (battery) power
m) Install NEW (Unused) Battery [date and sign] – Record Date:
n) Reset Battery Life Indicator
o) Install Protracting Actuation Device (PAD) – Record Date:
p) All visual seals in place and secure
q) Maintenance tag signed and in place
r) All required Warning and Hazardous Labels in place
Section 3 Comments:
 HERRENKNECHT COMMISSIONING CHECKLIST
(Form No. F-2020042)
2024-JAN-11 REV. 01 PAGE 3

ANSUL® Fire Suppression System test report per machine (Continued)

4. End-user reviews and signatures Yes No N/A

a) End-user Training and Owner/Operator Manual reviewed
b) Service and Maintenance Agreement has been signed by end-user
c) All end-user turn-over documentation complete – Record Date:

5. Closing Signatures and Requirements

a) Commissioning Agent, provide your Signature and Completion Date below.
b) Obtain the End-user Signature and Acceptance Date below.
c) Send a copy of this complete Commissioning Checklist with your invoice to
the Dealer / Bill-To Information listed above.
d) Email a copy (see Click to Submit button) of this Commissioning Checklist to:
ANSUL® Vehicle Systems Team (avst@jci.com or BE-Mar-avst@jci.com) Phone: 800-862-6785
Acceptance Signatures Certifying Distributor / Commissioning Agent End-User
Company Name
Name (type/print)
Title (type/print)
Signature (type/sign)
Completion Date

CLICK TO SUBMIT Form To:

ANSUL® Vehicle Systems Team

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ANSUL®, CHECKFIRE, and the product names in this material are marks and/or registered marks. Unauthorized use is strictly prohibited.