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' At ,y I NC Ar FIRE SAFETY SYSTEMS
AQUASAFErm FLOW TEST
ar 't VERIFICATION
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FORM
Aqu.aSAFETM Flow Test Verification Form
Affiance Important:Installing contractor must submit this
Member ID: ++ completed form.Failure to do so nullifies the
Company Name: 4 t l reig,t C J k..M�I, (Y system warranty.E-mail or fax completed form
I .i to the Uponor Fire Safety Design Department
Contact: I "N L.1v )O✓ 7 e—f at technical.services@uponor.com or 952.997.1731.
Phone: `1 /
cb 3 - ,f Q z (I ,tS For questions,contact Uponor Technical Services at
888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: 12 ce1"5..)
Job Name: Static pressure(not flowing)reading at incoming
Project Number 470
" water supply into home or at main shutoff: 0)
Job Address: tip �l G 54/1 So lovy gem/
/ Residual pressure(flowing)reading at incoming water
City: 'f� oc orat0
G
State,ZIP: /714 3
What time of day was the flow test taken?
For designs not provided by Uponor,complete the
following information. Flow test method used? alrucket 0 Flow Meter
Flow test gpm: l /-7 1
Company: How many gallons of water did the design predict
as required? l -7
Phone: Did the test meet or exceed design flow? lit'Yes 0 No
Fax: Which sprinkler did you flow?Number:/
Is the warning sign permanently attached close to the Location of head: y 4S J—
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main shutoff valve? I:]Yes 0 No
Date left in service with all valves open:
Was this system required by code?0 Yes ❑No
ri
Test Witnessed and Verified by:
Narpq I Sig aura I _.anon Date
/ Cc c.� Vl •• 7—/ 2-?
0
3
0
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Additional Explanations and Notes
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gl Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
1 Apple Valley,MN 55124 USA Web:www.uponor-usa.com