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�; .. . ...",„„.,i,. i )0i1 AQUASAFETM FLOW TEST
VERIFICATION
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FORM
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AquaSAFETM Flow Test Verification Form
Alliance Important Installing contractor must submit this
Member ID: f completed form. Failure to do so nullifies the
Company Name: /�j i) I CAN Z. �/11A1(t1 1j r system warranty. E-mail or fax completed form
1- to the Uponor Fire Safety Design Department
Contact: I'! 4c 19,1 u- at technical.services@uponor.com or 952.997.1731.
�.-- For questions,contact Uponor Technical Services at
Phone: 0.3 -"[n'7 '2 3 4 q,Cl 88g 594.7726 or technicalservices@uponor.com.
Fax: - Color of test orifice used: 'brey53
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Job Name: -C)�;: Static pressure(not flowing)reading at incoming
Project Number: // water supply into home or at main shutoff:
Job Address: i if/(o b $(l ' L5 w-
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Residual pressure(flowing) reading at incoming water
City: I J 9 �4 supply into home or at main shutoff: 7b
State,ZIP: Q 72?
What time of day was the flow test taken? l i• M
For designs not provided by Uponor, complete the
following information. Flow test method used? 'r' :ucket U Flow Meter
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Designer's Name: Flow test gpm: 1 , \
Company: _ How many gallons of water did the design predict
•i as required? as
Phone: — Did the test meet or exceed design flow?Ar,B'es U No
Fax: -- Which sprinkler did you flow? Number: M {
Is the warning sign permanently attached close to the Location of head: e d rrrsnr,r.., 3'
main shutoff valve? U Yes ❑No
Date left in service with all valves open:
Was this system required by code?U Yes L3 No
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Test Witnessed and Verified y:
"= Name Signatu --- Occupation Date
JY/14e G(eAcr I I 1,—._ '`'31) ".2 „S"2-2__
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Additional Explanations and Notes - ,
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g. Uponor,Inc. Tel:800.321.4739 i
5925 148th Street West Fax:952.997.1731
1 Apple Valley,MN 55124 USA Web:www.uponor-usa.com
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