Report (2) 4
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FIRE SAFETYA SYSTEMS
°` AQUASAFE, TM OW TEST
r
VERIFICATION
FORM
AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: 1 6 c� completed form.Failure to do so nullifies the
/ �g system warranty.E-mail or fax completed form
Company Name: +�(4C.nti[ (G1 �✓
/ to the Uponor Fire Safety Design Department
Contact: C7...
..'»1 V oo• (n 6w.�4 S at technicaiservices@uponor.com or 952.997.1731.
r- For questions,contact Uponor Technical Services at
Phone: 0 . 7— b S- _ For 594e.7726 or technical.services@uponor.com.
Fax. Color of test orifice used: �. j
Job Name: �r�/lp/�iff rtCC.. Static pressure(not flowing)reading at incoming
Project Number: ;at'6 CQV C.' water supply into home or at main shutoff: �S
Job Address: ,Zq?3 S� /� .
Residual pressure(flowing)reading at incoming water
City: supply into home or at main shutoff: t'�
State,ZIP:
What time of day was the flow test taken? /O!4 .
For designs not provided by Uponor,complete the
following information. Flow test method used?�jQ Bucket CI Flow
Meter
Designer's Name: Flow test gpm: �/
Company: How many gallons of water did the design predict
as required?
Phone:
Did the test meet or exceed design flow? Yes ❑No
Fax: Which sprinkler did you flow? Number:
Is the warning sign permanently attached close to the Location of head: r -*•
main shutoff valve? ❑Yes ❑No
Date left in service with all valves open:
11 Was this system required by code?'Yes ❑No
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Test Witnessed and Verified by:
" Name Sig e ,�" Occupation Date
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Additional Explanations and Notes Li
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p Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:95Z.997.1731
sApple Valley,MN 55124 USA Web:www.uponor-usa.com