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FIRE SAFETY SYSTEMS
AQUASAFETM FLOW TEST
VERIFICATION
FORM
AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: 7,_/ —/!J completed form.Failure to do so nullifies the
p y /_ �� system warranty.E-mail or fax completed form
Company Name: v N�� �" to the Uponor Fire Safety Design Department
Contact: 69/web/tri at technical.services@uponor.com or 952.997.1731.
C � l 7 `��✓� For questions,contact Uponor Technical Services at
Phone: -
G 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used:
Job Name: } �?ir4l�[� Static pressure(not flowing)reading at incoming
Project Number: :„74306/4 p ewe water supply into home or at main shutoff:
Job Address: -71t9 4411 Li,
Residual pressure(flowing)reading at incoming water
City: supply into home or at main shutoff: 6_o
State,ZIP:
What time of day was the flow test taken? [/1 4 4,t
For designs not provided by Uponor,complete the
following information. Flow test method used? VI Bucket CIFlow Meter
Flow test gpm: 1 6
Designer's Name:
Company: How many gallons of water did the design predict
as required? 1 7
Phone: Did the test meet or exceed design flow? 0-Yes ❑No
Fax. Which sprinkler did you flow?Number: 1----
Is the warning sign permanently attached close to the Location of head: � r AeSte/ o
main shutoff valve? ❑Yes ❑No
Date left in service with all valves open.
Was this system required by code?05 Yes ❑No
Test Witnessed and Verified by:
" Name Signature Occupation Date
0
Additional Explanations and Notes / Jh, , ar- 3 Z
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Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com