FACILITIES AND PROCEDURES AUDIT INFORMATION AND CONTENTS LIST (1911) Frequency:

FM APPROVALS - TELEPHONE NUMBER (781) 762-4300 FAX NUMBER (781) 278-0810

Issued: Replaces IndexNum: Current Job ID# ISO 9000 Certified Expire Previous Audit Date Approval Guide Volumes Section: Ownership
2/18/2016 10/14/2015 3029247F 0003029247 Yes 01/04/2018 12/9/2015 FIRE H SIPAI
Approval Customer: 5Elem Material Scientific (Jiangsu) Co L
Audited Premises: 5Elem Material Scientific (Jiangsu) Co Ltd
Street Address: 986 Machang Rd, Economic Development District
City/County: Jiangyan State: Zip Code: 225510 Country: China
Customer Contacts: Phone FAX E-Mail:
Sha Yuehua - President 86 523 88812200 86 523 88818855
[email protected]
Yu Xia - Engineering Manager (Contact) 86 523 88819944 86 15861018936 [email protected]
FM Approvals Contacts:
MacDonald,Brian K Technical Team Manager 401-567-5035 00268 [email protected]
Products To Be Audited: Is present list of FM Approvals products complete for this location? If not add/delete as necessary. Check here after
review _______yes________

1-1/2, 1-3/4, 2, 2-1/2 IN NOMINAL SIZE SINGLE AND DOUBLE JACKET WOVEN FIRE HOSE

Special Instructions:
5Elem Fire Hose Co Ltd is their former name - pjm - 11/1/2011

Description of Plant:
Fire hose manufacuting plant. Employee number is 200 and 25,000 sq. m building.
Directions to Plant:
Shanghai ---Huning highway-Xicheng highway -NJY highway-Jiangyan exit. It takes 2 hours from Wuxi to the site by car.

AUDITORS PLEASE NOTE: THIS FILE CONTAINS PERMANENT MATERIAL LISTED BELOW:
Complete this sheet and Form 279(Surveillance Audit Report). Request copy of missing items on last page of audit report.
If ISO 9000 Certificate has expired get replacement copy and attach to audit report.

Reviewed by:______________Review Date:____________________

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FM Approvals 2011
 IndexNum: 3029247F 1911-Revised 3/30/2009 5Elem Material Scientific (Jiangsu) 1000010535 L 1 3 18-Feb-16

Title: Surveillance Audit Report Document No: F 545

Issue Date: 28 February 2016 Issue No: 7

Auditor: Sun Jinxiang Customer Name: 5Elem Material Scientific

(Jiangsu) Co Ltd
Audit Date: 15-Mar-2016 Index Number: 3029247F

Audited Site: 5Elem Material Scientific Contact Person / Mrs. Yu Xia/ 15861018936
(Jiangsu) Co Ltd Phone:

Arrival Time: 13:00 Departure Time: 16:30

Audited Hours: 3.5h Report Hours: 0.5h

Reviewed by: Date Reviewed:

Select Current Audit Sequence Below:

Quarterly Audit 1 st 2nd 3rd 4th

st nd rd th
Quarterly Plus 1 2 3 4
Semi-Annual Audit 1st 2 nd

Annual Audit Not Performed *

Please Note: A check mark in a box with an asterisk (*) requires a written Audit Comment and if applicable a detailed
description in the Non-Conformance(s) section of this report.
A. Approval Guide / RoofNav Audit Comment / Findings
The purpose of this section is to: a) confirm who is responsible for maintaining the Approval Guide/RoofNav information; b)
verify that products identified on the “list” in site package are either manufactured at location, no longer manufactured or
manufactured elsewhere; c) Provide a simple listing of products produced at location to enable an auditor to examine each
within the course of a 2 year period.
1.
Is this site responsible for maintaining Approval Yes No * The site is responsible for
Guide/RoofNav Information?
maintaining AGI
If No, provide Name, Address, Contact, Email
Address and Telephone Number of responsible
site.

2.
Product confirmation - Using Approval Guide ,
RoofNav, 1911 or other product list provided as part
of the package for site audit;

Confirm current status of product (or material)

manufactured:
a) No longer manufactured (note Revision a) List of products no longer
Request required) manufactured (How validated-discussion
with who- name & title?)

N/A
Mrs. Yu Xia/ 15861018936

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FM Approvals 2011
 b) Manufactured elsewhere b) List of products manufactured
elsewhere inclusive of location and
contact. (How validated-discussion with
who- name & title?)

N/A
Mrs. Yu Xia/ 15861018936

c) List all FM Approved products that can

c) Manufactured in accordance with current be made at this site. Also provide notation
list (note any product produced with if models have production constraints that
auditor verifying any constraints e.g. impact auditor verification, such as only
produced once a year, on order only etc. made in Q1, or rarely made. (How
validated-visual or discussion with who-
name & title?)

1-1/2, 1-3/4, 2, 2-1/2 IN NOMINAL SIZE

SINGLE AND DOUBLE JACKET WOVEN
FIRE HOSE
On order only.
Mrs. Yu Xia

B. Subcontracting Audit Comment / Findings

1.
Since the last audit, has the customer Yes * N/A No No subcontractors changed.
subcontracted or changed subcontractors who Check the customer list.
manufacture specific electrical components,
assemblies, raw materials, (including hydraulic and
transformer fluid) used in their FM Approved
Products.

2.
If Yes, provide the name and address, and contact Yes N/A No *
person of any other sites performing manufacturing
operations to these Approved Product(s), and if
applicable, specify the part number or formulation in
the audit comment / findings field.

C. FM Approvals Required Testing and Assessment Guidance Audit Comment / Findings

For all Hydraulics and Electrical audits consult the section titled Manufacturer Responsibility in the Approval Reports, Audit
Manual, Auditor Production Checklist, etc.. For Building Materials audits, ensure that manufacturer is conducting tests as
specified in the Audit Manuals. This action should be accomplished by dedicating the necessary time to witness testing.
1.
Were specified tests as indicated in the referenced Yes N/A No * proof pressure test including elongation,
documents above being correctly performed on FM twist, warp and rise;
Approved products at the time of the audit? kink test; burst test; adhesion test; physical
test; thickness and internal diameter
If yes, specify each Approved Product (s) tests measurement required by standard 2111
conducted and results. If no, observe testing of section 5.4.
similar products or review previous test results and / and also the heat resistance test
or test procedures for required tests. Describe these Type No:C.F3.E.006
observation findings. Order number: 6242
date:2016-03-10
Pressure:3.4Mpa, time:60s
60rolls, 1828.8m.
• Approved Product Observation: inner diameter, thickness, kink test, burst

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FM Approvals 2011
 • Similar Product Observation: test are checked.

• Review of previous test : Result is OK.

2.
Does manufacturer have written test procedures for Yes No * All test items listed above are included in
the specified tests? procedure 5E/QC8.2.4-03d Rev. D/0

(Identify any test procedures by title/control number

and dates)

3.
Are provisions for instructions and / or installation, Yes N/A No * The provisions are in accordance with the
maintenance, and operation of product in approval reports.
accordance with the Approval Report(s)?

D. FM Approval Mark Audit Comment / Findings

To complete the following questions, consult the section titled Marking Requirements in applicable Approval Report.
Observe product in the manufacturing and finished goods areas. Note: Product is not considered FM Approved if shipped
without the Approval Mark.
1.
Are all outgoing shipments of FM Approved Yes N/A No *
Products or materials properly marked with the
manufacturer’s name, address, model / type
designation, and proper ratings in accordance with
the applicable drawing or approval report?

2.
Is the audited location responsible for applying the Yes No * stencilled on each length of the hose
FM Approval Mark?

(If no, state which facility has responsibility)

3.
Is the Approval Mark properly applied to all, and Yes N/A No * All information required by FM approval is
only, equipment / materials approved by FM applied to FM product only.
Approvals?

a) Is there a procedure to to ensure that the Yes N/A No * Procedure for management of FM Approval
Approved Mark is applied only to the FM marks: 5E/QC7.5.3-02 D/0
Approved products? Order number is used as specification of FM
mark.

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FM Approvals 2011
 b) If the Approval Mark is applied before final Yes N/A No * After final inspection.
acceptance is completed, is there a
procedure to ensure that the Approval
Mark is removed from any rejected
products or the product is made
functionally inoperative.?

E. Critical Drawings and Documentation Control Audit Comment / Findings

A critical document list, when available, will be provided in the site package. If a critical document list is not available in the
site package, consult the section titled Documentation in the Approval Reports. Critical document lists are not created for
Building Materials clients. Consult Building Materials audit manuals and / or Approvals Report.
1.
Does the audited facility have responsibility for
Yes No * DuPont Fluoroproducts
drawing / documentation control? Controlling by Manager's Office.

If no, indicate location of Design Control Facility.

(e.g.: contact person, address, phone )

2.
Does the audited facility have documented 5E/QB4.2.3
Yes No *
procedures for control of critical drawings / Document Control Procedure
formulations?

(Including how document changes may be

transmitted from design / drawing control
location).
3.
Do change procedures specify that all changes to Any changes have to be applied to FM
Yes No *
critical drawings / formulations be approved by
FM Approvals prior to implementation to
production?
4.
Are documentation levels and formulations in Accordance with Approval reports
Yes No *
accordance with Approval reports, audit manuals,
Revision Request forms, and /or critical
document lists (if any for specific Approval
reports)?

If no, customer is to be advised that this is a

requirement of the Master Approval Agreement.

Any changes made to controlled documents must

be submitted to FM Approvals via the Revision
Request form.
Customer is to submit the form electronically
to [email protected]

5.
List drawings that do not match FM Approvals revision levels in the Description of Non-conformance(s) section of this report.
Provide drawing number, project ID number, FM Approvals revision and current revision.

F. Quality Registrations Audit Comment / Findings

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FM Approvals 2011
 1.
Is the facility ISO 9001 registered? TUV NORD CERT GmbH.
Yes No
Number: 44 100 072066.
If yes, view copy of certificate and identify Expiration date: Jan. 04, 2016.
registrar, certification number name and
expiration date.

If ISO 9001 Registration is planned, please

provide timetable, contact name and telephone
number

2.
Does the manufacturer have any other Quality UL/CCC
Yes No
System Registrations such as ATEX, IECEx, CCC:Certificate for china compulsory product
CPR, etc.? certification.
No. 2012081802000319
If yes, please indicate the registrar, certification Expire date: 2018-07-09
number, name and expiration date.

G. Quality Procedures and Inspection Audit Comment / Findings

1.
Does the customer have an organized quality QCR: Xu Hongwei
Yes No *
management system? QAM: 5E-QA Rev.A/1 date on:2012-
10-20
If yes, customer must have all the following:
• Quality Control Representative
• Quality Assurance Manual
• Supporting Written Procedures

2.
Is product traceability documented from incoming Via production order and batch number
inspection to finished product?
Yes N/A No *
5E/QB7.5.3

3.
Incoming Inspection (If Applicable) Incoming inspection procedure:
a) Are incoming shipments identified and 5E/QC8.2.4-01 Rev A/0
checked for conformity with Yes N/A No *
specifications? Tensile testing and composition
verification.
b) Are non-conforming items identified and
Yes N/A No *
segregated? ZH\QMS\Q2\17
Non-conforming items will be rejected.

c) Are inspection procedures/records Yes N/A No *

maintained and available for review?

4.
In Process Inspection(if applicable) Procedure: 5E/QC8.2.4-02 A/0
a) Are inspection and test instructions hydro pressure test is performed on
available and used? Yes N/A No *
100% product in process.

5.
Final Inspection and Test (if applicable)
Yes N/A No * Final Inspection Procedure:
a) Are written final test and inspection 5E/QC8.2.4-03 D/1
procedures available and used?
Tests required by Clause 5.4 of Class
2111 are sample performed in every
b) Are items identified to indicate final Yes N/A No * order.
acceptance?

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FM Approvals 2011
 6.
Review Customer Complaints Procedure
(Specifically FM Approved product)

Yes In-place with evidence of activity 5E/QC7.2.3-01

N/A In-place with no evidence of activity Have the record form.
No * No procedure in place

7.
Have any products that are FM Approved or were Yes No If No: Provide the name of the person
FM Approved been the subject of a product being audited, their title and the
recall? statement that no recalls have been
issued.

Mrs. Yu Xia

a) Was the recall due to a non-

conformance that affects the product Yes No
approval? If Yes: Provide a detailed account of
the recall activity, actions taken and
gather supportive documentation if
available.

8.
Have any products that are FM Approved or were If Yes: Provide detail of the non-
FM Approved been the subject of a field
Yes No conformance and obtain applicable
notification alerting customers to a non- documentation regarding the field
conformance? notification.

9.
Are any identified product complaints above Yes * No Certified products are not complaining
suspected to require a Notification of Concern? occur.

H. Equipment Calibration Audit Comment / Findings

1.
Are test and measurement equipment Yes No * All equipments used are sent out to third agency to
calibrations traceable to national standards? be calibrated.

(If no, describe basis used to determine

accuracy)

2.
Do written calibration procedures exist?
Yes No * Procedure: 5E/QC7.6-02 Rev D/0

Also equipment checklist is available.

Form number: 5E/QD7.6-06

3.
Identify contractor(s) providing calibration service(s), if any. Taizhou Institute of Measurement and Testing
Technology

Jiang yan Institute of Measurement and Testing

Technology

4.
Are due date tags applied to calibration Yes No * All is controlled
equipment and are the due date tags current? Check the pressure gauge No.26257
Cert. No. : JD2015100781
If no, describe tracking / recall system. Expire date：09-08-2016

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FM Approvals 2011
 I. Approved Product Validation Audit Comment / Findings
The purpose of this section is to document the products validated for compliance during the audit, and the reference
documents used. Note: The auditor shall provide a summary of whether the audited products were found to be in
compliance or otherwise in this section.
1.
Identify products / models / materials for which a List of products for which a detailed audit was performed. Note below product
detailed audit was performed. model, inspection / test performance, results’ satisfactory / un-satisfactory.
(Note to auditor: Detailed product class checklists are available for reference
during this activity)

Checked the production, inspection, calibration, documents & records.

5ERR15-500FF
Production records checked.

Type No:C.F3.E.003
Order number: 6242
date:2016-03-10
pressure:3.4Mpa time:1min
60rolls, 1828.8m.
inner diameter, thickness, kink test, burst test are checked.

Result is OK.

2.
List the Approval Reports and/or Audit Manuals 3026286-AR-3029247
associated with the audited product(s).

3.
Identify the drawings/formulations validated during Checked the procedures, records and visited the production line as well.
the detailed audit.

J. Surveillance Audit Summary

The purpose of this section is to document the surveillance audit history of FM Approved products listed for this audit site
during prior visits. Note: The auditor shall update this summary during subsequent visits to ensure that all the
manufacturer’s listed products are subjected to audit.

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FM Approvals 2011
 Production Examined Compliance
at time of during this Confirmed
visit? visit?
Approval
Date Report/ Audit Product Description / Notes
Manual Yes No Yes No Yes No

15-Mar- 3026286-AR- Checked the production, inspection,

16 3029247 calibration, documents & records.

Surveillance Audit Non-Conformance Report and Corrective Action Request

Categories of Non-Conformance:
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FM Approvals 2011
 Approval Guide Approval Mark CDL Variation
Subcontracting Approval Documentation Calibration
Testing Requirements Quality Systems Product Validation
Formulation Deviation

Description of Non-Conformance(s)
NC Naming Convention as follows NC-YYMMDD-01

N/C #:
Category of Non-Conformance:
Non-Conformance:
Proposed Corrective Action:

N/C #:
Category of Non-Conformance:
Non-Conformance:
Proposed Corrective Action:

N/C #:
Category of Non-Conformance:
Non-Conformance:
Proposed Corrective Action:

Add additional non-conformances by cutting and pasting the format

Please identify any Non-Conformances identified above suspected to require a Notification of Concern by
N/C#:

Additional Auditor Comments: ISO 9001 Registration had updated, pls comcern. New certification see
attachment.

Customer Comments:

Ongoing Non-conformance:

Agreed Response Date: Before the next audit Contacts: Mrs. Yu Xia Date: 2016-03-15

Auditor: Sun Jinxiang

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FM Approvals 2011
Attachment:

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FM Approvals 2011