Confirmation of the extinguisher system manufacturer/installer:
The manufacturer/installer of the extinguisher system hereby confirms that the extinguisher system has
been designed and constructed according to the valid statutory directives based on DIN 14497 and
according to the latest state-of-the-art.
The extinguisher system has been handed over in a fully functional condition (up to the interface for the
alarm interface).
Calculation of the oxygen concentration according to DGUV Rule 105-001:
The CO
2
concentration of the breathable air in the installation area may not exceed 5%.
The currently measured room volume in the installation area amounts to approx. ______ m
3
The total gas concentration at the tripping of the extinguisher system in the installation area currently amounts
to ________ Volume %
Formula for the calculation of the CO
2
concentration in %
CO
2
gas volume = Total weight of CO
2
= CO
2
gas volume in m
3
2
CO
2
proportion = CO
2
gas volume (m
3
) x 100 (%) = CO
2
concentration in %
Room volume (m
3
)
1 kg CO
2
corresponds to approx. 0.5 m
3
CO
2
. The actual weigh of CO
2
is quoted on the extinguisher container.
If the calculation of the oxygen concentration according to DGUV Rule 105-001cannot be carried out, the room
volume must be quoted as the length, width and height. The calculation will be subsequently carried out by the
manufacturer of the extinguisher system.
Length: __________________ Width: ____________________ Height: ________________________
Remarks: __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
______________________________________ __________________________________________
Place / Date Stamp + Signature of Operator
_____________________________________ __________________________________________
Place / Date Signature of Manufacturer/Installer
Handover executed by (company):
_____________________________________ __________________________________________
Place / Date Stamp & Name in block capitals and signature
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