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PUBLIC WORKS DEPARTMENT 80 Columbia Ave Marysville, WA 98270 (360)363-8100 SITE FIRE HYDRANT UTILIZATION PERMIT APPLICATION AND HYDRANT BACKFLOW PREVENTION ASSEMBLY / METER LOAN AGREEMENT FEES AND INSTRUCTIONS FEE SCHEDULE* Deposit $1200.00 (up to $1150.00 refundable) Set-up fee $50.00 (non-refundable) rental $50.00 (non-refundable) Usage $3.50 per 1000 gallons The applicable hydrant use fee, water consumption fee, and any costs to repair or replace City equipment or property will be deducted from the original deposit prior to refund. INSTRUCTIONS The maximum length of time a meter and backflow assembly (BFA) can be checked out is one year. If a meter and BFA is needed for a period exceeding one year, a new meter and BFA will be issued, and the original unit must be returned for inspection and maintenance. The City will provide the customer a fire hydrant meter and a double check valve assembly (DCVA) or a reduced pressure back flow assembly (RPBA) according to the need, adapters for either a fire or garden hose, and instructions (as shown below) for proper installation. The deposit shall be refunded after the equipment has been returned in good condition and inspected by Utilities personnel, and all charges are paid. 1. Attach the meter to the designated hydrant outlet. 2. Connect the fire hose to the meter at one end, and to the backflow prevention assembly at the other end. Observe the directional arrows on the backflow assembly. 3. With the 2-inch control valve closed, use the hydrant wrench to open and close the hydrant. The hydrant must be in the full open position while using it. 4. The control valve on the meter MUST be used to prevent damage to the hydrant and to the water distribution system. Always open and close the control valve slowly to prevent surges or water hammer that could cause damage to the water system. *Per Appendix C, Fire Hydrant Utilization Program/July 2002 ---PAGE BREAK--- PUBLIC WORKS DEPARTMENT 80 Columbia Ave Marysville, WA 98270 (360)363-8100 HYDRANT METER CHECKOUT FORM and PERMIT PERMIT HOLDER INFORMATION Date Name: Contact: Phone: Contact: Phone: Address: Email **City Project – Deposit Only Deposit rec'd Check # Rec'd by METER INFORMATION Designated Hydrant Location Estimated Return Date Leaded-Type or Lead-Free Meter: Leaded-Type* Lead-Free The CCS should ensure that the Site Fire Hydrant Utilization Permit holder receives applicable items as marked below and understands the instructions for proper installation and use. For Low Hazard Use: Double Check Valve Assembly with Serial number For High Hazard Use: Reduced Pressure Backflow Assembly Serial number Hydrant Valve Wrench 2-inch x 3/4-inch Bushing with 3/4-inch Garden Hose Adapter Fitting Additional equipment/comments: ---PAGE BREAK--- PUBLIC WORKS DEPARTMENT 80 Columbia Ave Marysville, WA 98270 (360)363-8100 STATEMENT OF UNDERSTANDING The undersigned applicant hereby agrees to hold and save harmless the City of Marysville from any and all claims for damages, costs, expenses or causes of action that may arise of installation and maintenance of the improvement or other equipment use hereto applied. The undersigned further agrees to remove the equipment and return it to the City of Marysville upon notice from the City and agrees to reimburse the City for loss or damage to the assembly or city property. I have received the components specified and understand the instructions for their use. I understand this permit expires in one year. Issue Date Expiration Date Signature of Permit Holder *FOR LEADED-TYPE METER RENTALS ONLY The undersigned applicant acknowledges the equipment being received is of a leaded-type and certifies that any and all usage of this equipment will comply with the requirements and exemptions of the Reduction of Lead in Drinking Water Act. The undersigned certifies that the equipment will not be used for potable services. EPA interprets “potable services” to be services or applications that provide water suitable for human ingestion (e.g. drinking, teeth brushing, food preparation, dishwashing, maintaining oral hygiene). I acknowledge I have received a copy of EPA’s “Summary Of The Reduction Of Lead In Drinking Water Act And Frequently Asked Questions” and agree to follow the provisions therein. Failure to comply with these regulations may result in repossession of equipment and forfeiture of deposit. Signature of Permit Holder METER READ Checked out by Meter reading Date Checked in by Meter reading Date Incoming Condition/Additional Comments: ---PAGE BREAK--- PUBLIC WORKS DEPARTMENT 80 Columbia Ave Marysville, WA 98270 (360)363-8100 HYDRANT USE PERMIT PUBLIC WORKS WORKSHEET (INTERNAL USE ONLY) INSPECTIONS Date Read By Date Read By FEES Deposit $1200.00 Refundable (up to $1,150.00) Set-up fee $50.00 Non-refundable rental $50.00 Non-refundable, number of months Total usage $3.50 Per 1000 gallons Other