Report (3) •
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' , , , a — 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: completed form.Failure to do so nullifies the
A I I l__ /pI system warranty.E-mail or fax completed form
Company Name: /'► �►.-b.in
g to the Uponor Fire Safety Design Departmerrt
Contact: /44 In 005 Let.. lOr2 6.-5 at technical.services@uponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: 503 "c 197 2 - 3/{ 9.0 ggg 594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: 1:sre..53
Job Name: \`-C) Static.pressure(not flowing)reading at incoming
Project Number: //� water supply into home or at main shutoff:
Job Address: Jf/.352 5t✓ 1p5� /'ilk
0'J Residual pressure(flowing)reading at incoming water
City: / 9 6-4 supply into home or at main shutoff: 7b
State,ZIP- 917??3
What time of day was the flow test taken? t er4"--
' For designs not provided by Uponor,complete the
following information. Flow test method used? Nit ucket ❑Flow Meter
Designer's Name: Flow test gpm:
Company: How many gallons of water did the design predict
a as required? f1 7
Phone: Did the test meet or exceed design flow?eirXes ❑No
Fax: Which sprinkler did you flow?Number: /4 - /
Is the warning sign permanently attached close to the Location of head: 7?e'dut.16..n-, a
main shutoff valve? 0 Yes J No
Date left in service with all valves open:
m Was this system required by code?0 Yes ®No
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Test Witnessed and Verified :
Name Signatu Occupation Date
`Name„ cry er r ."-3`P '2—3—Z-Z
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T Additional Explanations and Notes
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Uponor,Inc. Tel:800.321.4739
5925148th Street West Fax:952.997.1731
g Apple Vailey,MN 55124 USA Web:www.uponor-usa.com
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