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Emergency Contact & Annual Smoke Detector/Carbon Monoxide Detector Test Report

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Emergency Contact & Annual Smoke Detector/Carbon Monoxide Detector Test Report
The Fire Department performs yearly inspections to ensure the safety of our residents. This form assists building managers with the inspection process.
City of Coon Rapids Fire Department 11155 Robinson Drive, Coon Rapids, MN 55433 763-767-6429 FAX 763-767-6531
BUSINESS INFORMATION:
Business Name*
Contact Person*
Business Phone*
Business Fax
Business Email Address*
Business Address: Include suite # and Zip Code*
BUSINESS OWNER INFORMATION:
Business Owner Name*
Owner Phone*
Fax
Business Owner Email Address*
Business Owner Address*
PROPERTY MANAGEMENT:
Property Management*
Management Phone*
Management Fax
Management Contact*
Management Email*
Management Address*
Emergency Call List: Tell us how to contact you in the event of an emergency outside business hours. Please provide at least 3 contacts.
Emergency Contact 1 Name*
Emergency Contact 2 Name*
Emergency Contact 3 Name*
Emergency Contact 1 Phone*
Emergency Contact 2 Phone*
Emergency Contact 3 Phone*
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Page 1

COON RAPIDS FIRE DEPARTMENT GUIDELINES Annual test report for local (unit) smoke and carbon monoxide detectors
Name of facility*
Street Address*
Facility Manager*
Phone*
Individual Smoke and Carbon Monoxide Detectors - To be filled out by facility manager
Total number single station (individual unit) smoke detectors*
Date smoke detectors tested:*
Smoke detectors passed (total)*
Smoke detectors failed (total)*
Smoke detectors fixed or replaced*
Total number single station (individual unit) Carbon Monoxide Detectors*
Date carbon monoxide detectors tested*
Carbon monoxide detectors passed*
Carbon monoxide detectors failed*
Carbon monoxide detectors fixed or replaced*
All individual smoke and carbon monoxide detectors have been tested and are in working order as of this date.
Manager Signature*
Type name as signature
Date*

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City of Coon Rapids
11155 Robinson Drive NW
Coon Rapids, MN 55433
City Hall Hours:
M-F 8 am to 4:30 pm
Phone: 763-755-2880
Fax: 763-767-6491
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