MECKLENBURG COUNTY
FIRE MARSHAL'S OFFICE
PRIVATE FIRE HYDRANT TESTING RELEASE FORM
Authorizing Party or Person:
Name of Property or Business:
Address of Property or Business:
Contact Party or Person Telephone Number:
The above Party or Person authorizes the Mecklenburg County Fire Marshal’s Office to conduct an inspection and test
of the Owner’s private hydrant at the above location.
Under no circumstance shall the Mecklenburg County Fire Marshal’s Office be liable in any manner for the failure to
conduct any inspection or test. The Authorizing Party or Person above shall continue to be responsible for all
maintenance of such hydrant, including, but not limited to, painting, repairing, and maintaining unobstructed visual and
physical access to all such hydrants. In addition, the Authorizing Party or Person is, and shall continue to be,
responsible for the costs of any and all water used to inspect and/or test such hydrant.
The Authorizing Party or Person hereby releases, and shall indemnify and hold harmless the County and its officers
and employees from any liability, loss, and cost, including, but not limited to, liability for property damage, loss of
income, personal injury, and reasonable attorney’s fees, arising or allegedly arising from the condition, operation,
testing, or inspection of the subject private hydrant and related improvements.
This the ______________ day of
Party or Person Authorizing Participation:
Owner/Responsible Party or Person (circle one and print):
Address:
Signature and Title:
Telephone:
County Official Obtaining Authorization:
PEOPLE • PRIDE • PROGRESS • PARTNERSHIPS
2145 Suttle Avenue • Charlotte, North Carolina 28208-5237 • (980) 314-3070
melissa.burgess@mecklenburgcountync.gov