Inspection, Testing and Maintenance of Private Fire Service Mains

Service Company / Date of Service / Time / Last Service Date
Weekly
Monthly / Quarterly
Semiannual / Annual
Fifth year
Owner: / Phone:
Fax:
Contact Person: / Phone:
Fax:
Building Name: / Address: / City: / Postal Code:

“”Yes - Satisfactory “X” No - Unsatisfactory N/A Not applicable (Explain “X” No answers in comments)

Weekly/Monthly / Exposed piping is free from leaks, physical damage
Relief port on reduced backflow prevention assembly / and corrosion?
free of discharge? / Exposed piping is properly restrained?
Sealed control valves and valves on backflow / Fifth Year Inspection Item
prevention assemblies: / Check valves internally inspected and all parts operate
Normal position? / properly?
Accessible with seals in place? / Tests
Free from external leaks? / Quarterly
Provided with appropriate identification? / Control valves opened until spring or torsion is felt in the
Quarterly / rod then closed back one quarter turn?
Hose houses? / Valve supervisory devices indicate movement?
Semiannually / Annual
Monitor nozzles free of leaks, damage and corrosion? / Monitor nozzles move through full range?
Monitor nozzles flowed an acceptable amount of water?
Hydrants inspection or after each use: / Hydrants flowed until clear (at least one minute)?
Dry Barrel and Wall Hydrants / Dry barrel hydrants drain in a least one hour?
Accessible & operating wrench available? / Dry barrel hydrants requiring pumping are identified?
Caps in place and threads on outlets in good repair? / All control valves operated through full range and returned
Free from ice or water in barrel? / to normal?
Free from leaks or cracks? / Backflow devices passed backflow test?
Main valves and drain valves in good repair? / Backflow devices passed full flow test?
Operating nut in good condition? / Fifth Year Test
Wet Barrel Hydrants / Exposed and underground piping passed flow test at expected
Accessible and operating wrench available? / flows?
Free from leaks at outlets and top of hydrant? / Annual Maintenance
Free from cracks in hydrant barrel? / Mainline strainers cleaned?
Caps in place and threads on outlets in good repair? / Hose/hydrant houses and equipment in usable condition?
Main valves and drain valves in good repair? / Hydrant caps, stems, plugs, and threads lubricated?
Operating nut in good condition? / Hydrants free of ice, snow and damage?
Mainline strainers free from plugging and corrosion? / Monitor nozzles lubricated?
Comments:
I state that the information on this form is correct at the time and place of my inspection, and that all equipment was tested in conformance with applicable codes and the Manufacturers requirements and at this time was left in operational condition upon completion of this inspection except as noted in comments.
Technician Stamp / Date / Time / Owner or Authorized Agent

ASTTBC F6 07/041 of 1