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State of California Business, Consumer Services and Housing Agency Department of Housing and Community Development Division of Codes and Standards Mobilehome and Special Occupancy Parks Program

PRIVATE FIRE HYDRANT TEST AND CERTIFICATION REPORT

All parks must return this form to the enforcement agency for the park.

Part 1. IDENTIFICATION—PARK AND PARK OPERATOR

Part 2. CERTIFICATION EXCEPTIONS

If any of the following applies—you do not need certification, but you must complete this section.

☐ Hydrants are publicly owned and maintained. Water Company Name___

☐ No hydrants AND park was built before September 1, 1968. Date of Construction ___

☐ No hydrants AND park has 14 or less total lots. Number of lots ___

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

Part 3. ANNUAL FIRE HYDRANT OPERATION TEST

To be completed by authorized Certifier ONLY. Standpipes are considered hydrants for certification requirements.

Certifier: Initial your verification in the appropriate column.

All NO answers are violations and will prohibit the issuance of the park's 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

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. ___

Telephone ___ Email ___

Printed Name___ Title___

Signature_____ Date of Certification_____

Part 6. APPROVAL FOR CONTINUED USE OF EXISTING SYSTEM—COMPLETED BY LOCAL FIRE AGENCY ONLY

Agent Name ___ Title ___

Badge Number Signature

HCD MP 532 (Rev. 10/25)

INSTRUCTIONS Submit this form by email to: ParksPTO@hcd.ca.gov or by mail to: HCD—Mobilehome Parks Program P.O. Box 278180 Sacramento, CA 95827-8180

HCD—Mobilehome Parks ProgramP.O. Box 278180Sacramento, CA 95827-8180

Part 1. IDENTIFICATION—PARK AND PARK OPERATOR

Park Name and Park ID #: Enter the name of the park and park identification number as shown on the Permit to Operate.

Park Address: Enter the physical address of the park.

Park Operator: Enter the name, address, telephone number, and email address of the park operator.

Part 2. CERTIFICATION EXCEPTIONS

These certificate 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.

IF ANY OF THESE EXCEPTIONS APPLY TO YOUR PARK, YOU DO NOT NEED TO COMPLETE PARTS 3-5.

Part 3. ANNUAL FIRE HYDRANT OPERATION TEST*

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

• Stems and valves fully operate, open and close freely, and have the proper lubrication.
• Caps, seals, and threads are undamaged.
• Are provided physical protection if subject to vehicular damage.
• Has a minimum of 36 inches of clear space around hydrant(s).
• Outlets are between 14 and 24 inches above grade. Standpipe outlets need not be a specific height but must be readily accessible.
• Is clearly identified or marked for easy location in an emergency.
• That are 1 1/2 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 PARK OWNER/OPERATOR'S SIGNATURE VERIFYING AN EXCEPTION IS REQUIRED IN PART 3.

Part 4. FIVE-YEAR FIRE HYDRANT WATER FLOW TEST* — to ONLY be completed every five years

Barrel size: Enter the barrel or riser diameter measured in inches.

Flow: Enter the measured flow in gallons per minute (GPM).

Pressure: Enter the residual pressure measure in pounds per square inch (PSI).

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: Enter the telephone number of the person, agency, or entity certifying the test results. Email: Enter the email address of the person, agency, or entity certifying the test results. Printed 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 the 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.

For more information, refer to California Code of Regulations, title 25, commencing with section 1300 and/or 2300.

• VIOLATIONS: If any answers in Part 3. ANNUAL FIRE HYDRANT OPERATION TEST are NO, and/or Part 4. FIVE-YEAR FIRE HYDRANT WATER FLOW TEST 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. 10/25) Page 2