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FIRE SAFETY SYSTEMS
01
i. .r ' AQUASAFETM FLOW TEST
VERIFICATION
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` ' 1. `" I FORM
AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: Ic ‘"2' completed form. Failure to do so nullifies the
system warranty.E-mail or fax completed form
Company Name: Liokzr7 Piunbi,.t to the Uponor Fire Safety Design Department
Contact: (/ '�"�r BU1J,Ir e..-0. at technical.services@uponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: .0 3 (a G 7 I ? / 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: 3.+RG
Job Name: PO Sh Static pressure(not flowing)reading at incoming
Project Number: ...$-7�� 66 3 /S water supply into home or at main shutoff: s
Job Address: /414/6 ' .S u 6)a 6l9 Cil ls)-
+� Residual pressure(flowing)reading at incoming water
/City: i6A00-0 supply into home or at main shutoff: 3i
State,ZIP: Cl►`
What time of day was the flow test taken? 5=60
For designs not provided by Uponor, complete the
following information. L Flow test method used? U Bucket Flow Meter
Designer's Name: 1t/A.✓ 342,1ec,c, Flow test gpm. 7
Company: 0�d n/0►G How many gallons of water did the design predict
as required? / '7
Phone: 4-9�/ "7)61
�� �9 7 t 7/ Did the test meet or exceed design flow? air 0 No
/Fax: d Which sprinkler did you flow?/ Number: M/� //
Is the warning sign permanently attached close to the Location of head: ,add°vo^N— .:
main shutoff valve? ❑Yes ❑No
Date left in service with all valves open: �ji— 0_
Was this system required by code?0 Yes ❑No
Test Witnessed and Verified by:
e / �—S. n Occupation
) Date
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Additional Explanations and Notes
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Uponor,Inc. Tel:800.321.4739
E 5925 148th Street West Fax:952.997.1731
1 Apple Valley,MN 55124 USA Web:www.uponor-usa.com