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

Park Name ParkID#
Park Address
CityCA Zip
Park Operator Name
Park Operator Address
TelephoneEmail
ID
Park Name Park
Park Address
City
Zip
Park Operator Name
Park Operator Address
Telephone
Email

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___

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 ___

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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 ___

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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.)

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.

CERTIFICATIONSYESNOCORRECTED & PASSED
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. Area around all hydrants has a minimum of 36 inches of unobstructed access.
5. All hydrant 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 11/2-inch hydrant has an approved hose in a marked enclosure.
YES_1. Hydrant stems and valves operate fully, freely, and are properly lubricated.
NO_1. Hydrant stems and valves operate fully, freely, and are properly lubricated.
CORRECTED & PASSED_1. Hydrant stems and valves operate fully, freely, and are properly lubricated.
YES_2. All hydrant threads and caps are undamaged.
NO_2. All hydrant threads and caps are undamaged.
CORRECTED & PASSED_2. All hydrant threads and caps are undamaged.
YES_3. Where subject to vehicular damage, hydrants are physically protected.
NO_3. Where subject to vehicular damage, hydrants are physically protected.
CORRECTED & PASSED_3. Where subject to vehicular damage, hydrants are physically protected.
YES_4. Area around all hydrants has a minimum of 36 inches of unobstructed access.
NO_4. Area around all hydrants has a minimum of 36 inches of unobstructed access.
CORRECTED & PASSED_4. Area around all hydrants has a minimum of 36 inches of unobstructed access.
YES_5. All hydrant outlets are 14 inches to 24 inches above grade. (Standpipe outlets need not be a specific height, but must be readily accessible.)
NO_5. All hydrant outlets are 14 inches to 24 inches above grade. (Standpipe outlets need not be a specific height, but must be readily accessible.)
CORRECTED & PASSED_5. All hydrant outlets are 14 inches to 24 inches above grade. (Standpipe outlets need not be a specific height, but must be readily accessible.)
YES_6. Each hydrant is clearly identified or marked.
NO_6. Each hydrant is clearly identified or marked.
CORRECTED & PASSED_6. Each hydrant is clearly identified or marked.
YES_7. Each 1 ½-inch hydrant has an approved hose in a marked enclosure.
NO_7. Each 1 ½-inch hydrant has an approved hose in a marked enclosure.
CORRECTED & PASSED_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'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

Park owner or operator

Part 4. FIVE-YEAR FIRE HYDRANT WATER FLOW TEST

Hydrant NumberBarrel Size (inches)Flow (GPM)Pressure (PSI)
1
2
3
Barrel Size (inches)_1
Flow (GPM)_1
Pressure (PSI)_1
Barrel Size (inches)_2
Flow (GPM)_2
Pressure (PSI)_2
Barrel Size (inches)_3
Flow (GPM)_3
Pressure (PSI)_3
Hydrant NumberBarrel Size (inches)Flow (GPM)Pressure (PSI)
4
5
6
Barrel Size (inches)_4
Flow (GPM)_4
Pressure (PSI)_4
Barrel Size (inches)_5
Flow (GPM)_5
Pressure (PSI)_5
Barrel Size (inches)_6
Flow (GPM)_6
Pressure (PSI)_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. ___

Certifier Name
License Class and No
Address

Telephone ___ Email ___

Telephone
Email

Printed Name___ Title___

Printed Name
Title

Signature_____ Date of Certification_____

Date of Certification
Signature

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

Agent Name ___ Title ___

Agent Name
Title

Badge Number Signature

Badge Number
Signature

HCD MP 532 (Rev. 10/25)