HomeMy WebLinkAboutSeven Mile Duck Club HCD Hydrant Cert 2020 STATE OF CALIFORNLA
DEOIATMEHT OF HOUSING PHD COMMUNITY DEVELOPMENT
ONISPX OF COOES MO STANDARDS
PRIVATE FIRE HYDRANT TEST AND CERTIFICATION 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-loENTrFIOATION Park Name: I.f_. orvivr3.Yh H✓n+IM r ltib Park IOW 09 I2.81-me
Park Address. '1 LOt St,.CA rule Lo-n6
City. tvrla^n CA ZIP: 4S'94
Park Operator Name L.t R-n!)&u-,44S Phone Number S30-4'O'3-CV-c-
Park Operator Address and City ZSO UAILfw(nraGn 4ue. Ste 370 04.2.o.re4 93-97/.,
Part 2-CERTIFICATION EocEPlION3-You do not need certification.but must complele this sadiOn if any of the following applies.
❑Hydrants are publicly owned and maintained-Water Company Name
❑No hydrants and park was built before September 1,1968-List Date of Construction' / /
❑No hydrants rg�i park has 14 or less total lots-Enter Number of Lots:
❑No pinata hydrants and park was built after September 1.1968.(Specific exception at the time of construction.)
Part 3-ANNUAL FIRE HYDRANT OPERATION TEST (IniHalverificatien in the appropriate solemn)
(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.
4.Around all hydrants is a minimum of 36 inches of unobstructed access.
5 All hydrants outlets are 14 Inches to 24 inches above grade.
(Standpipe outlets need not bee specific height.but must be readily accessible.) ✓
6 Each hydrant is clearly identified Or marked,.
7 Each 1%-inch hydrant has an approved hose in a marked enclosure
All"NO"answers are violations and will prohibit the Issuance of the park Permit to Operate.
lVerification: L/
I verify der penalty of perjury that either this park is exempt .53Cll.- 1111 a�tw�--mo III
from testing requirements or the hydrant operation is in compliance Park owner or operator
Part 4-Flue-YEAR FIRE HYDRANT WATER FLOW TEST To be completed by authorized certdier ONLY.
Barrel Size Flow Pressure Barrel See Flow Pressure
37V .2(PSI)
'YJ_ 4 (inches) (GPM) (PSq
1
2 5
3 6
Foe more THANE HYDRA/MIN THE Celi ATTACH AN emnlasAr.LIST LIMO Tie MOW.ABOVE
(OPM)-OAu0ee PER M enne.IPSI)-Reeou.mamas IN eorws rae esuwe RA:H.
PART 5-CERTIFICATIONTEST RESyyS
Certifier Name.C/ 11 AOL,TI 6L License Class and No.f.4. *1"7$3137--
Address/7Z, Fc-.r.a ter+. r lr:!c,n C A• 95,7R
Telephone Number. �br)2 E-Mail Address 54•A..anii3.Y OFF..Olfof-o✓ aeut
Pnnted Name 5492
1be I RPT.Odlyf7N ci Signature Cam-- nate of Test Co / ir/ ZCZO
Part 6-APPROVALFOR CONTINUED usE OF EXISTING SYSTEM-To BE COMPLETED BY LOCAL FIRE AGENCY ONLY
Agent Name Tide
Badge Number Sionature