Report (3) e . r� sla62" oo (9s�
uponor
FIRE SAFETY SYSTEMS
AQUASAFETM FLOW TEST
t'3't"'. ° . J VERIFICATION
, Z4Yr F — 41I1
ar
FORM
.) z
r
AquaSAFETM Flow Test Verification Form
Alliance Important Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
system warranty.E-mail or fax completed form
Company Name: Al) I R A(p Piwn b I oN
t of to the Uponor Fire Safety Design Department
Contact: NcC1z at technical.services@uponor.comor952.997.1731.
For questions,contact Uponor Technical Services at
Phone: 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: Bra 5 5
Job Name: Static pressure(not flowing)reading at incomin'
Project Number: I-1(e water supply into home or at main shutoff:
Sw4.
Job Address: /yy/GI (/ 5 laic
Residual pressure(flowing) reading at incomina water
City: a✓er MFO Y1 supply into home or at main shutoff: TO
State,ZIP: OR olloos-7 `l
What time of day was the flow test taken?
For designs not provided by Uponor,complete the
following information. Flow test method used? lBucket ❑Flow Meter
Designer's Name: Flow test gpm: 17 t
How many gallons of water did the design predict
Company: as required? r7
Phone: Did the test meet or exceed design flow? 'Yes ❑No
Fax: Which sprinkler didAlt
you
flow? Number: A
A Is the warning sign permanently attached close to the Location of head: tt'i l r iM
�YS� `-+l M
main shutoff valve? ❑Yes ❑No
,�(j Date left in service with all valves open:
c Was this system required by code?ALA Yes ❑No
Test Witnessed and Verified by:
Name Signa re Occupation Date
MI( lu(tr�ss Pivrnber' /o— ig
0
;�u V o
n
a
a
Additional Explanations and Notes
a
,
LLI
s Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
i Apple Valley,MN 55124 USA Web:ww v.uponor-usa.com