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, i I ) 1,.� . � "` FIRE SAFETY SYSTEMS
if: V , AQUASAFETM FLOW TEST
ai }_ VERIFICATION
aC. 4
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.FORM
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AguaSAFETM.Flow Test Verification Form
Alliance Important Installing contractor must submit this
Member ID: J./Jiii
! completed form.Failure to do so nullifies the
Company Name: t (tree, o system warranty.E-mail or fax completed form
7to the Uponor Fire Safety Design Department
Contact: / •a#4. "f] N-ve, e), at technical.services@uponor.com or 952.997.1731.
Phone: 5 03_ ��`� t?/�� — For questions,contact Uponor Technical Services at
888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: 1)(r;..>5
Job Name •< � Static.pressure(not flowing)reading at incoming
Project Number: ! ' O o F c"o 5water supply into home or at main shutoff: V t�
Job Address: I6427.51.>gd,1,�, g Lti
I / Residual pressure(flowing)reading at incoming water
City: 7t l d l d- supply into home or at main shutoff:
State,ZIP: o) 7 2."
•
What time of day was the flow test taken? I d��ti f
For designs not provided by Uponor, complete the
following information. Flow test method,used? ,tt'Bucket CIFlow Meter
Designer's Name: _ Flow test gpm:_-/77 _ \
Company: How many gallons of water did the design predict
•i — as required? /7
Phone:
Did the test meet or exceed design flow? j Yes ❑No
Fax: — Which sprinkler did you flow?Number: 1/ iir
s �i SL Is the warning sign permanently attached close to the Location of head:_ � 'rr_'a!-rem ,.ice& 2 / 4S
main shutoff valve? 0 Yes ❑No
Date left in service with all valves open:
Was this system required by code?I.d'Fes ❑No
3 f
•
Test Witnessed and Verified lam:
Name 1 Sign ture 9 . _ Occupatio Date
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0
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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
1_ Apple Valley,MN 5512.4 USA Web:www.uponor-usa.com
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