Hcd Mp 532 Form – Fill Out and Use This PDF

STATE OF CALIFORNIA

DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT

DIVISION OF CODES AND 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 - IDENTIFICATION

Park Name:

Park ID#

Park Address:

City:

CA

ZIP:

Park Operator Name

Phone Number

Park Operator Address and City

Part 2 - CERTIFICATION EXCEPTIONS - You do not need certification, but must complete this section 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 and park has 14 or less total lots - Enter Number of Lots:

No private hydrants and park was built after September 1, 1968. (Specific exception at the time of construction.)

Part 3 - ANNUAL FIRE HYDRANT OPERATION TEST	(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.

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 be a specific height, but must be readily accessible.)

6.Each hydrant is clearly identified or marked.

7.Each 1 ½ -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.

Verification:

I verify under penalty of perjury that either this park is exempt

from testing requirements or the hydrant operation is in compliance.

Park 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

(inches)

(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

License Class and No:

Address

Telephone Number

E-Mail Address

Printed Name

Title

Signature

Date of Test

/

/

Part 6 – APPROVAL FOR CONTINUED USE OF EXISTING SYSTEM –TO BE COMPLETED BY LOCAL FIRE AGENCY ONLY

Agent Name

Title

Badge Number

Signature

HCD MP 532 (REV 1/07) SIDE 1

INSTRUCTIONS FOR COMPLETING HCD MP 532*

Return the completed form to the Area Office that issues your permit to operate with a copy to your local fire district

Northern Area Office	Southern Area Office
9342 Tech Center Drive, Suite 550	3737 Main Street, Suite 400
Sacramento, CA 95826	Riverside, CA 92501

PART 1 - IDENTIFICATION

Park ID# - Enter the park Identification Number as shown on the permit to operate.

Park Name - Enter the name of the park as shown on the permit to operate.

Park address - Enter the physical address of the park.

Enter Park Operator Name, phone number, and address.

PART 2 - CERTIFICATION EXCEPTIONS – These certification requirements do not apply to:

-Parks with public hydrants, where the local water district owns the water or hydrant system and performs regular hydrant testing. List the name of the water company.

-Parks, without hydrants, constructed prior to September 1, 1968.

-Parks, without hydrants, with 14 or less total spaces.

-Parks, without hydrants, constructed after September 1, 1968.

All parks with hydrants must have them tested and certified regardless of park size or date of construction.

THE PARK OWNER/OPERATOR’S SIGNATURE VERIFYING AN EXCEPTION IS REQUIRED IN PART 3.

PART 3 - ANNUAL FIRE HYDRANT OPERATION TEST **

Initial the appropriate column to indicate whether the hydrant(s):

1.stems and valves fully operate, open and close freely, and have the proper lubrication.

2.caps, seals and threads are undamaged.

3.which are subject to vehicular damage, are provided physical protection.

4.has a minimum of 36 inches of clear space around all hydrants.

5.outlets are between 14 & 24 inches above grade. Standpipe outlets need not be a specific height, but must be readily accessible.

6.is clearly identified or marked for easy location in an emergency.

7.that are 1 ½ inch, have a 75-foot hose on a rack, or reel contained in an enclosed cabinet marked “FIRE HOSE” in 4- inch contrasting letters.

The operational test may be verified by a park owner/operator during the four years between the five-year water flow certification. If the park performs the operational test, the owner/operator’s signature verifying compliance is required. During the five-year test, only the entity performing the water flow test may certify the operational test.

PART 4 - FIVE-YEAR FIRE HYDRANT WATER FLOW TEST (To only be completed every five years by a certified person) ** Barrel size – Enter the barrel or riser diameter measured in inches.

Flow – Enter the measured flow in gallons per minute.

Pressure – Enter the residual pressure measured in pounds per square inch.

PART 5 - CERTIFICATION OF TEST RESULTS

This section is to be completed by the fire agency responsible for fire suppression in the park, local water supplier, Licensed Fire Protection Engineer, or C-16 Fire Protection Contractor witnessing and certifying the test information.

Certifier Name – Enter the name of the person, agency or entity certifying the test results.

Contractor’s classification and number – Enter the California Contractors State License Board classification and license number or the license number for a California licensed fire protection engineer.

Address - Enter the address of the person, agency, or entity certifying the test results. Telephone Number - Enter certifiers’ telephone number.

E-Mail Address – Enter certifiers’ e-mail address, if available. Name - Print the name of the person certifying the test.

Title – Enter the title of the person certifying the test. Signature –Required signature of person certifying test. Date – Enter the date of the certification.

PART 6 - APPROVAL FOR CONTINUED USE OF EXISTING SYSTEM – COMPLETED BY LOCAL FIRE AGENCY ONLY. This section may only

be completed by a local fire agency when a private fire hydrant cannot be repaired to meet these standards, given local conditions, and the fire agency responsible for fire suppression in the park approves its continued use or use of alternative fire protection methods.

*Refer to Title 25, California Code of Regulations, Article 6, commencing with Section 1300 and/or 2300. **VIOLATIONS: If any answers in Part III – Annual Fire Hydrant Operation Test are “No,” and/or the Five-Year Fire Hydrant Flow Test of Part IV does not meet the minimum requirements, the park is in violation. The park operator/owner is responsible for correction of violations. Failure to correct violations may result in the park not being eligible to renew its annual permit to operate.

HCD MP 532 (REV 1/07) SIDE 2