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FIRE SAFETY SYSTEMS
t ik AQUASAFETM FLOW TEST
VERIFICATION
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FORM
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A uaSAFE�R"t Flow Test Verification form
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/� Alliance Important:Installing contractor must submit this ,•
V completed form. Failure to do so nullifies the
Member l _-.h or
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Company system warranty.E-mail or fax completed form
Company Name: 61"1•--- liajiiw bg''`A- to the Uponor Fire Safety Design Department
j�' �sa,LeA__ at technical.services@uaon__._Qr com or 9.52.997.1731.
Contact: •-. :.- r For questions,contact Uponor Technical Services at
Phone: ra 3 6o t?� 1 7/3t — 888.594.7726 or technical serviiCC-----ponor.com,
Fax: _.__._. Color of test orifice used: 4.
Job Name: _i-2(. S11-is-tt'-- Static pressure(not flowing)reading at incoming
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ate
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water supply into home or at main shutoff: A.
Project Number: 3)-5-75-`f- oc 3 _
Job Address; S Residual pressure(flowing)reading at incoming water
City, T i'. J'�.l�0 supply into home or at main shutoff: 3
State,ZIP: dry —— Ayj
41-
What time of day was the flow test taken?
For designs not provided byUponor,complete the f
p p Flow test method used? 0 Bucket ( Fiow Meter
following information.
( Flow test gpm: i 2
Designer's Name. cvAte/ ,,, eak_ t-"
How many gallons of water did the design predict i
Company: �llPoNO — ii
as required? /7 t
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phone: .. _. f' ?-�s '-____ Did the test meet or exceed design flow? �r es 'Li No
Fax: }S"c).. ? 1731
Which sprinkler did you flow? Number: bs O IL
Is the warning sign permanently attached close to the Location of head: ttg,itM
main shutoff valve? ❑Yes LA No Atiii
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Date left in service with all valves open: - 30
Was this system required by code?U Yes i No '
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Test Witnessed and Verified by: i
-eitlf)c, (....-, Si tun. Occupation Date �,
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;; Additional Explanations and Notes
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Uponor,Inc, Tel 800.321.4739
5925 148th Street West Fax:952.997,1731
Apple Valley,MN 55124 USA Web:vwr auponor-usa.cern