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i I FIRE SAFETY SYSTEMS
AQUASAFETM FLOW TEST
1. 11
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VERIFICATION
FORM
AcitiaSAFE Flow Test Verification Form
Alliance ..)gl...7 Important:installing contractor must submit this
I Member ID: 4-13 4. completed form.Failure to do so nullifies the
Company Name: 14)0(On Rom b ita system warranty.E-mail or fax completed form
to the Uponor Fire Safety Design Department
Contact: CII,e 1311442P1441. at technicalservices@uponor.com or 952.997.1731.
Phone: 6-03- (pb/- /rat For questions,contact Uponor Technical Services at
PAR 594.7726 or technicalserviceseuvionor.com.
Fax:
Color of test orifice used: e3OLCIC
Job Name: 500k4N 2;‘)Ai-Te 4(clCe Static pressure(not flowing)reading at incomi
Project Number: L43 4 6"b1' 002. 11.2. water supply into home or at main shutoff:
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Job Address: 16,3671 SW CO,OfotJO _____Le
Residual pressure(flowing)reading at inc in water
City: li/CIC supply into home or at main shutoff:
State,ZIP: O
What time of day was the flow test taken?
For designs not provided by Uponor,complete the
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following information. Flow test method used? Bucket DI Flow Meter
iDesigner's Name: ow test gpm: /
Company: How many gallons of water did the design predict
as required? a
Phone:
Did the test meet or exceed design flow? 16 Yes 0 No
Fa •
Which sprinkler did you flow?Number: 0•L4
is the warning sign permanently attached close to the Location of head:
main shutoff valve? 0 Yes ID No
tot 22-23
Date left in service with all valves open:
Was this system required by code?0 Yes 0 No
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. Test Witnessed and Verified by:.
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.s. Additional Explanations and Notes
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‘?. Uponor,Inc. Tel:800.321.4739
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5925 148th Street West Fax:952.997.1731
I Apple Valley,MN 55124 USA Web:www.uponor-usa.com
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