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�' ; FIRE SAFETY SYSTEMS
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- 1 VERIFICATION
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' l- FORM
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AquaSAFETM Flow Test Verification Form
Alliance Important Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name: /4 Ili r.v, ` PIt„vM 0.4 system warranty.E-mail or fax completed form
( to the Uponor Fire Safety Design Department
Contact: 1- -vt H he... -1®✓KG•-S at technical.services@uponor.com or 952.997.1731.
!fib — 2 2i 3 4f _ For questions,contact Uponor Technical Services at
Phone: ' e 888.594.7726 or technical.services@uponor.com.
Fax: � — Color of test orifice used: 'C-s. 5
n
Job Name: t 1� Static.pressure(not flowing)reading at incoming
Project Number: water supply into home or at main shutoff: 'C='Job Address: I y/$L Sd!WV -•
Residual pressure(flowing)reading at incoming water
City: `,f,l� supply into home or at main shutoff: 76
State,ZIP: 9'72.23 1144 '
What time of day was the flow test taken?
For designs no;provided by Uponor,complete the
following information. Flow test method�.used? $ucket ❑Flow Meter
Desi ner's Name: Flow test gpm:
9
Company: _�—�___Y___ How many gallons of water did the design predict
';
as required? 1 7
Phone: - Did the test meet or exceed design flow? aYes ❑No
Fax: ------------ Which sprinkler did you flow?Number: i - 3
Is the warning sign permanently attached close to the Location of head: ec o evv..2---
main shutoff valve? 0 Yes ❑No
Date left in service with all valves open:
Was this system required by code?❑Yes ❑ND
Test Witnessed and Verified by:
Name ..Sig r Occup n Date
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En Additional Explanations and Notes
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Uponor,Inc. Tel:800.321.4739 t
5925148th Street West Fax:952.997.173I
1 Apple Valley,MN 55124 USA Web:www.uponor-usa.com