HomeMy WebLinkAbout068-341-027 CF ArchiveSTATE OF CALIFORNIA
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
PRIVATE FIRE HYDRANT TEST AND CERTIFIGATION REPORT
ALL PARKS MUST RETURN THIS FORM TO THE ENFORCEMENT AGENCY FOR THE PARK
(SEE THE REVERSE SIDE FOR INSTRUCTIONS ON COMPLETING THIS FORM)
Part 1 - IDENTIFICATION UA-Ir
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Park Name: CYl � V Paff Park ID# 04-opqq �
Park Add ess:
City: oA. D V
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Park Operator Name ��� /`� � �l , , Phone Number.
Park Operator Address and Ci 3 Or��'
P City
Part 2 - CERTIFICATION EXCEPTIONS - You do not need certification, but must complete this section if any of the following applies:
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L .ydrants are publicly owned and maintained - Water Company Name
No hydrants and park was built before September 1 , 1968 - List Date of Construction: I 1
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No hydrants and park has 14 or less total lots - Enter Number of Lots:
ONO private hydrants and park was built after September 1, 1968. (Specific exception at the time of construction.)
Part 3 - ANNUAL FIRE HYDRANT OPERATION TEST p VD�� (Initial verification in the appropriate column)
(Standpipes are considered hydrants for these requirements) YES NO CORRECTED
1. Hydrant stems and valves operate fully, freely, and are properly lubricated.
2. All hydrant threads and caps are undamaged.
3. Where subject.to vehicular damage, hydrants are physically protected. X
4. Around all hydrants is a minimum of 36 inches of unobstructed access.
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.5. All hydrants outlets are 14 inches to 24 inches above grade.
(Standpipe outlets need not be a specific height, but must be readily accessible.)
6. Each hydrant is clearly identified or marked. A.
7. Each 1 Y2 -inch hydrant has an approved hose in a marked enclosure. F
All "NO" answers are violations and will prohibit thAssua a of the park Permit to operate.
Verification: '
verify under penalty of perjury that either this park is exempt ��-
from testing requirements or the hydrant operation is in complian . OPark owner or operator
Part 4 — FIVE-YEAR FIRE HYDRANT WATER FLOW TEST To' be completed by authorized certifier ONLY.
Barrel Size Flow Pressure Barrel Size Flow Pressure
(inch �(GPM (PSI) (inches) (GPM) (PSI)
1 4
2 ' 5
3 6
FOR MORE THAN 6 HYDRANTS IN THE PARK, ATTACH AN ADDITIONAL LIST USING THE FORMAT ABOVE.
(GPM' -GALLONS PER MINUTE. (PSI) - RESIDUAL PRESSURE IN POUNDS PER SQUARE INCH.
PART 5 — CERTIFICATION OF TEST RESULTS
Certifier Name r f041 License Class and No: 4
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Address d
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Telephone Num er - < . E -Mail Address 1 oil - - -b
CA 95969
Printed Name' Title to 10 M
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Signature c Date of Test
Part 6 — APPI'OVAL FOR CONTINUED USE OF EXISTING SYSTEM —TO BE COMPLETED BY LOCAL FIRE AGENCY ONLY
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Agent Name Title
Badge Number Signature
HCD MP 532 (Rev 1/07) Side I
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