Report (2) .7.7„:fi.,:;:,,,T,,, : I iii, ":'''',:"'''y � Ni UpOf101
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. �rr FIRE SAFETY SYSTEMS
�: - AQUASAFETM OW TEST
VERIFICATIONSAFE FL
FORM
y
AquaSAFETM Flow Test Verification Form_
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
j3OL Pl�,,i6,^� system warranty.E-mail or
Company Name: to the Uponor Fire Safety Designfax Departcompletedmentform
Contact:
/Cori Kdq e 9 at technical.services@uponor.com or 952.997.1731.
c For questions,contact Uponor Technical Services at
Phone: q7 I 235, oSGK 888.594.7726ortechnical.services@uponor.com.
Fax: Color of test orifice used:
Job Name: s�' r�•�/1 � Static pressure(not flowing)reading at incomy ,
,e (� tr3F R2 water supply into home or at main shutoff:' es'
Project Number: 73 �Z "'p
Job Address: '" ot5 so "
Residual pressure(flowing)reading at incomin water
City: 7i-6a/� supply into home or at main shutoff: �s ��
State,ZIP: er�yo^ 1� OO• A/"
What time of day was the flow test taken?
For designs not provided by Uponor,complete the
Flow test method used? XI Bucket ❑Flow Meter
following information.
Flow test gpm: i 7
Designer's Name:
How many gallons of water did the design predict
Company: as required? ��
Phone: Did the test meet or exceed design flow? iti Yes ❑No
Fax: Which sprinkler did you flow?Number: 4. ' I
Is the warning sign permanently attached close to the Location of head:
main shutoff valve? ❑Yes C.]No Date left in service with all valves open: (Q�Q✓�3
Was this system required by code?0 Yes ❑No
Test Witnessed and Verified by:
Name Signature Occupation Date
Additional Explanations and Notes
E Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
3 Apple Valley,MN 55124 USA Web:www.uponor-usa.com