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FIRE SAFETY SYSTEMS
:, AQUASAFETM FLOW TEST
VERIFICATION
FORM
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AquaSAFETM Flow Test Verification Form
Alliance �( Important:Installing contractor must submit this
Member ID: 1 1 completed form.Failure to do so nullifies the
L system warranty.E-mail or fax completed form
Company Name: tlroL+�C(L (KK^{',4
to the Uponor Fire Safety Design Department
Contact: 6.CtO•.1 h�`+yry �' at technical.services@uponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: ��-77 6v 3 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used:
Job Name: Q-1',r`L_ Static pressure(not flowing)reading at incoming
Project Number 3e15 )6 r B(1 6 water supply into home or at main shutoff: 7S-
Job Address: I 11 5-4) ✓ht SQ&
Residual pressure(flowing)reading at incoming water
City: supply into home or at main shutoff: 6.S"
State,ZIP:
What time of day was the flow test taken? /044Is,
For designs not provided by Uponor,complete the
following information. Flow test method used? 'Bucket ❑Flow Meter
Flow test gpm:
Designer's Name:
Com an How many gallons of water did the design predict
p Y as required?
Phone:
Did the test meet or exceed design flow? U.Yes U No
Fax: Which sprinkler did you flow?Number: t(
Is the warning sign permanently attached close to the Location of head: Plofo.e.s4.c.,- fittyl/ j11i41
main shutoff valve? ❑Yes ❑No
Date left in service with all valves open:
Was this system required by code?*_Yes ❑No
72.
Test Witnessed and Verified by:
Name Signature Occupation Date
D
T Additional Explanations and Notes 10f;", d')
El
Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com