Texas Department of Insurance
State Fire Marshal’s Office Mail Code 112-FM
333 Guadalupe • P. O. Box 149221, Austin, Texas 78714-9221
512-305-7900 • 512-305-7922 fax • www.tdi.state.tx.us	
Contractor's Material and Test Certificate for Underground 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 	

PLANS	Accepted by approving authorities (names) 	
	Address 	
	Installation conforms to accepted plans		Yes		No
Equipment used is approved		Yes		No
If no, state deviations

INSTRUCTIONS	Has person in charge of fire equipment been instructed as to location of
control valves and care and maintenance of this new equipment?		Yes		No
If no, explain
	
	Have copies of appropriate instructions and care and maintenace
charts been left on premises?		Yes		No
If no, explain	
LOCATION
	Supplies buildings	 	
UNDERGROUND PIPES AND JOINTS
	Pipe types and class 
	Type joints 
	
	Pipe conforms to 	 		Standard		Yes		No
Fittings conform to	 		Standard		Yes		No 
If no, explain 	
	Joints needed anchorage clamped, strapped or blocked in 		Yes		No
accordance with _________________ standard
If no, explain	

TEST DESCRIPTION	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 excess of 150 psi (10.3 bars) for two hours.
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		No
If no, explain 	

FLUSHING	How flushing flow was obtained
	Public water		Tank or reservoir		Fire pump	Through what type of opening
	Hydrant butt	    	Open pipe	
TESTS	Lead-ins flushed according to _______________ standard by (company)		Yes		No
If no, explain 
	
	How flushing flow was obtained
	Public water		Tank or reservoir		Fire pump	Through what type of opening
	Y connection to flange spigot	     	Open pipe	

HYDROSTATIC TEST	All new underground piping hydrostatically tested at
	 		psi	for	 		hours	Joints covered
		Yes		No	

LEAKAGE
TEST	Total amount of leakage measured
	 		gallons	 		hours	
	Allowable leakage
	 		gallons	 		hours	
HYDRANTS	Number installed 
	Type and make 
	All operate satisfactorily
		Yes		No	

CONTROL VALVES	Water control valves left wide open		Yes		No
If no, state reason
Hose threads of fire department connections and hydrants interchangeable with those of
the fire department answering alarm		Yes		No	

REMARKS	Date left in service  	

Signature
	Name of installing contractor	C  of  R  No.     SCR-
	
	Contractor’s Address	City	State	Zip	
	Tests witnessed by	
	For property owner (signed)	Title 	Date 	
	For Installing contractor (signed)	Title	Date 	
Additional explanation and notes	
		
	I certify that the information herein is true and that this portion of the sprinkler system was installed in accordance with Article 5.43-3, Texas Insurance Code and the rules and standards adopted by the State Fire Marshal’s Office.	
RME	
Responsible Managing Employee (signature) 	
CERTIFICATION	Responsible Managing Employee (print or type name) 	
	RME License Number 	Date 	
DISTRIBUTION:	    Original COPY 1 posted at site.     	COPY 2 for the installing firm    		COPY 3 for approving authority.