Fillable Contractor'S Material And Test Certificate printable pdf download

Texas Department of Insurance

Mail Code 112-FM

State Fire Marshal’s Office

333 Guadalupe • P. O. Box 149221, Austin, Texas 78714-9221

512-305-7900 • 512-305-7922 fax •

Contractor's Material and Test Certificate for

nderground Piping

PROCEDURE

Upon completion of work, inspection and tests shall be made by the contractor’s representative and witnessed by an owner’s representative. All defects shall be corrected

and system left in service before contractor’s personnel finally leave the job.

A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities, owners, and the contractor. It is understood the

owner’s representative’s signature in no way prejudices any claim against contractor for faulty material, poor workmanship, or failure to comply with approving authority’s

requirements or local ordinances.

Property Name

Date

Property Address

City

State

Zip

Accepted by approving authorities (names)

Address

PLANS

Installation conforms to accepted plans

Yes

Equipment used is approved

Yes

If no, state deviations

Has person in charge of fire equipment been instructed as to location of

control valves and care and maintenance of this new equipment?

Yes

If no, explain

Have copies of appropriate instructions and care and maintenace

INSTRUCTIONS

charts been left on premises?

Yes

If no, explain

Supplies buildings

LOCATION

Pipe types and class

Type joints

UNDERGROUND

Pipe conforms to

_________________

Standard

Yes

PIPES AND

Fittings conform to

_________________

Standard

Yes

JOINTS

If no, explain

Joints needed anchorage clamped, strapped or blocked in

Yes

accordance with _________________ standard

If no, explain

FLUSHING: Flow the required rate until water is clear as indicated by no collection of foreign material in burlap bags at outlets such as hydrants and

blow-offs. Flush at flows not less than 390 GPM (1476 L/min) for 4-inch pipe, 880 GPM (3331 L/min) for 6-inch pipe, 1560 GPM (5905 L/min) for 8-

inch pipe, 2440 GPM (9235 L/min) for 10-inch pipe, and 3520 GPM (13323 L/min) for 12-inch pipe. When supply cannot produce stipulated flow rates,

obtain maximum available.

HYDROSTATIC: Hydrostatic tests shall be made at not less than 200 psi (13.8 bars) for two hours or 50 psi (3.4 bars) above static pressure In

TEST

excess of 150 psi (10.3 bars) for two hours.

DESCRIPTION

LEAKAGE: New pipe laid with rubber gasketed joints shall, if the workmanship is satisfactory, have little or no leakage at the joints. The amount of

leakage at the joints shall not exceed 2 quarts per hour (1.89 L/hr) per 100 joints irrespective of pipe diameter. The leakage shall be distributed over

all joints. If such leakage occurs at a few joints, the installation shall be considered unsatisfactory and necessary repairs made. The amount of

allowable leakage specified above can be increased by 1 fl oz per inch valve diameter per hour (30 mL/25 mm/hr) for each metal seated valve isolating

the test section. If dry barrel hydrants are tested with the main valve open so the hydrants are under pressure, an additional 5 oz per minute (150

mL/min) leakage is permitted for hydrant.

New underground piping flushed according to

_________________ standard by (company)

Yes

If no, explain

How flushing flow was obtained

Through what type of opening

Public water

Tank or reservoir