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STATE OF CALIFORNIA <br /> DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT <br /> DIVISION OF CODES AND STANDARDS <br /> PRIVATE FIRE HYDRANT TEST AND CERTIFICATION REPORT <br /> ALL PARKS MUST RETURN THIS FORM TO THE ENFORCEMENT AGENCY FOR THE PARK <br /> SEE THE REVERSE SIDE FOR INSTRUCTIONS ON COMPLETING THIS FORM) Q' <br /> Park Name: � <br /> Part 1 -IDENTIFICATION Park IDfk [ i r•[- <br /> Park Address: y_,&WSC <br /> City: 1_2 y <br /> � �_ _CA ZIP: 4 �� Y <br /> r <br /> Park Operator Name f oev S e (Ud"" � nn'' ` 'Phone Number 2e9 - 3G If- S'),76 <br /> Park Operator Address and City /�L 6 1 W's � d �' !.J. a [? yZ__ <br /> Part 2-CERTIFICATION EXCEPTIONS-You do not need certification, but must complete this section if any of the following applies: <br /> ❑ Hydrants are publicly owned and maintained-Water Company Name <br /> ❑ No hydrants and park was butt before September 1, 1968- List Date of Construction: <br /> .-�o fijii�re'Fifs aFdp'�Rt�Bs'1�Or ieAs"t"oflti'idt�-fitter Nunlbar or Lars: - —_ __ . _-__._ _ � ____._ <br /> ❑ No private hydrants and perk was built after September 1, 1968. (Specific exception at the time of construction.) <br /> Part 3-ANNUAL FIRE HYDRANT OPERATION TEST (Initial verification In the appropriate column) <br /> (Standpipes are considered hydrants for these requirements) YES NO CORRECTED <br /> 1. Hydrant stems and valves operate fully, freely, and are properly lubricated. X <br /> 2. All hydrant threads and caps are undamaged" X <br /> 3. Where subject to vehicular damage, hydrants are physically protected. K <br /> 4. Around all hydrants Is a minimum of 36 inches of unobstructed access. K <br /> 5.All hydrants outlets are 14 Inches to 24 inches above grade. X <br /> (Standpipe outlets need not be a specific height, but must be readily accessible.) <br /> 6. Each hydrant Is Clearly identified or marked" <br /> 7. Each 1 Y-Inch hydrant has an approved hose in a marked enclosure. <br /> All"NO" answers are violations and will prohibit the Issuance of the park Permit to Operate. <br /> =Vern '� �/y of perjurythat either this park is exempt / a-- '�'t.� • ln'� 1��d <br /> ments or the hydrant operation is In compliance. Park owner or operator <br /> Part 4- FIVE-YEAR FIRE HYDRANT WATER FLOW TEST To be completed by authorfrad certifier ONLY. <br /> Barrel Size Flow Pressure Barrel Size Flow Pressure <br /> (Inches) (CPM) (Pan (irxdIea) (GPM) (PSI) <br /> 2 5 <br /> 3 6 <br /> FOR MORE THAN 6 HYDRANTS IN THE PARK,ATTACH AN ADDITIONAL LIST USING THE FORMAT ABOVE. <br /> (GPM)•GALLONS PER MINUTE. (PSI)-RESIDUAL PRESSURE IN POUNDS PER SQUARE RICH. <br /> PART 5—CERTIFICATION OF TEST RESULTS <br /> Certifier Name License Class and No: <br /> Address <br /> Telephone Number_ E-Mail Address <br /> Printed Name Title <br /> Signature Date of Test <br /> Part 6—APPROVAL FOR CONTINUMOSE OF Exuirnma sYSTEM-TO BE COMPLETED BY LOCAL FIRE AGENCY ONLY <br /> Agent Name Title <br /> Badge Number SI nature <br /> HCD MP 512(Rev I/0T)Side I , <br />