Report (2) 4 , , 1VI&42'1—d 0115
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a,° ' FIRE SAFETY SYSTEMS
,. AQUASAFETM FLOW TEST
�° y`i 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
Company Name: /I/ n ItG Y'G (at,,h 10 Jai system warranty.E-mail or fax completed form
/I ! to the Uponor Fire Safety Design Department
Contact: / GrJY/F� %t,1i,a..-S at technical.services@unonor.com or952.997.1731.
�/9b For questions,contact Uponor Technical Services at
Phone: So3- `/s a ;
888.594.7726 or technical.services@uponor.com.1
Fax: Color of test orifice used: 13(�S s
Job Name: { -OrS 5tatic.pressure(not flowing)reading at incoming`
Project Number: ! 7 c J ,/water supply into home or at main shutoff: K v
Job Address: /C7 27 L �l./ 1(jf�RV
/ Residual pressure(flowing)reading at incoming water
City: 01 5A(ef: supply into home or at main shutoff: 76
State,ZIP: 9 7'7'7 3 — "Poi
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What time of day was the flow test taken?
For designs not provided by Uponor, complete the
following information. Flow test method,.used? Bucket ❑Flow Meter
Designer's Name: _ Flow test gpm:_
Company: How many gallons of water did the design predict
i as required?
Phone: Did the test meet or exceed design flow? ®Yes ❑No
Fax: Which sprinkler did you flow? Number: Hs.- //
Is the warning sign permanently attached close to the Location of head: '3CA mr>rw
main shutoff valve? 0 Yes 0 No
Date left in service with all valves open:
Was this system required by code?❑Yes 0 Ns)
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Test Witnessed and Verified 11 y:
Name�� 11 (cr,leG( --
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Sign ture__,_� Occupa Date
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Additional Explanations and Notes
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1 Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.173 i
Apple Valley, MN 55124 USA Web:www.uponor-usa.com
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