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' AQUASAFETM FLOW TEST
�s� VERIFICATION
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FORM
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AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: ^ •
completed form.Failure to do so nullifies the
Company Name: 1 Di- I)(t ' t 9 system warranty.E-mail or fax completed form
1. ko uc.t to the Uponor Fire Safety Design Department
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Contact: at technical.services@uponor.com or 952.997.1731.
\. 41 I ..z35.•p(p�L For questions,contact Uponor Technical Services at
I; Phone: 888.594.7726 or technical.services@uponor.com.
' Fax: Color of test orifice used:
I Job Name: S0K'''/ ri 14(-1.�rc.t,C
Static pressure(not flowing)reading at incomi
Project Number 1 141 .� F 0a RI water supply into home or at main shutoff' g'.
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Job Address: /15 1�/ Static
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Residual pressure(flowing)reading at incomingew�a"ter
City: T1� supply into home or at main shutoff: 1$
State,ZIP: 017
What time of day was the flow test taken?Q; A."
For designs not provided by Uponor,complete the
following informati . Flow test method used? T Bucket ❑Flow Meter
Flow test gpm: 1 7
Designer's Name:
Company: How many gallon of water did the design predict
as required? //
Phone: Did the test meet or exceed design flow? Yes ❑No
Fax: Which sprinkler did you flow?Number: 4 1
Is the warning sign permanently attached close to the Location of head:
main shutoff valve? ❑Yes ❑No 'e ,,,/��3
Date left in service with all valves open:
Was this system required by code?❑Yes U No
fi
5` Test Witnessed and Verified by:
Name Signature Occupation Date
o
Additional Explanations and Notes
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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