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- FIRE SAFETY SYSTEMS
4 ir" AQUASAFETM FLOW TEST
VERIFICATION
FORM
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AquaSAFE' Flow Test Verification Form
Alliance Importantin Installing contractor must submit this
Member ID: ILO2- completed form.Failure to do so nullifies the
Company Name: WovO ?i.0.A -9 J system warranty.E-mail or fax completed farm
to the Uponor Fire Safety Design Department
Contact: Cf, 'f 81,Qnqv) at technical.services@uponor.com or 952.997.1731.
$0 (p(,7 17® For questions,contact Uponor Technical Services at
Phone: 1 RR[t5947726 or technical,services@uponor.com,
Fax: Color of test orifice used: 3IaCV
Job Name: SO .)\4,, ;oeC 1 e aci to Static pressure(not flowing)reading at incoming ,
Project Number: 43 463 r 669 ie2 water supply into home or at main shutoff: (DID p6.
Job Address: I6?Gq Srr) CO )cut16 id,
Residual pressure(flowing)reading at incpinpg water
City: —t't0A(d supply into home or at main shutoff: 105i
State,ZIP: 008-0I
What time of day was the flow test taken? /d%019
For designs not provided by Uponor,complete the
following information. Flow test method used?A Bucket Cl Flow Meter
Designer's Name: Flow test gpm: /g E'M
How many gallons of water did the design predict
Company:
as required? 17
Phone: Did the test meet or exceed design flow?)4 Yes CI No
Fa Which sprinkler did you flow?Number: -, ..i
Is the warning sign permanently attached close to the Location of head:
main shutoff valve? Cl Yes ❑No 921 23
Date left in service with all valves open:
Was this system required by code?CI Yes ❑No
Test Witnessed and Verified by:s. Date ^��
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Additional Explanations and Notes
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6 Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
1 Apple Valley,MN 55124 USA Web:www.uponor-usa.com