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FIRE SAFETY SYSTEMS
�'. ' AQUASAFETM FLOW TEST
"' lX VERIFICATION
FORM
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.quaSAF'Etm Flow Test Verification Form
!�� Alliance Important:Installing contractor must submit this
i Member ID: 1'� �' completed form. Failure to do so nullifies the
system warranty.E-mail or fax completed form
Company Name: U+1t t �l�Uµ ►t.v� - to the Uponor Fire Safety Design Department
+,441"i J at technicalseryices@uponor.com or 952.997.1737.
Contact: 61.1t' 'I
For questions,contact Uponor Technical Services at
Phone: SO 3 Co v 7 t?>r1 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used 1 .It-
Job Name: h4'S..AL Static pressure(not flowing)reading at incoming
Project Number: 7S 7 water supply into home or at main shutoff: Ic
Job Address' Pic Jtc S•,► etbAS!'
Residual pressure(flowing)reading at incoming water
City l.r�l7al�r✓) supply into home or at main shutoff: -3
State,ZIP: de.
What time of day was the flow test taken?
For designs not provided by Uponor,complete the �"�
fallowing information. Flow test method used? 0 Bucket 126Tow Meter
Designer's Name: Irv./ g Q,,,C),c l-' Flow test gpm: /7
Company: t, dr.tte.,. How many gallons of water did the design predict
as required?/7
Phone: ff 5f 7
Did the test meet or exceed design flow? es 0 No
Fax: �-_1f? J 7 31
Which sprinkler did you flow?Number Ik..403 1t 6'
V,
Is the warning sign permanently attached close to the
main shutoff valve? tJ Yes U No Location of head: t" M *f� r<6�a
Was this system required bycode? Date left in service with all valves open /0 ,�3e) . ,k s s C:INo
Test Witnessed and Verified by:
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,� r Occupation
Date
Additional Explanations and Notes
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Uponor,Inc.
5925 148th Street West TeL 800.321,4739
`":• Apple Valley,MN 55124 OSA Fax:9952,997.1711
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Web:www.uponor-nsa.com