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54.) G)Gt/Gf� FIRE SAFETY SYSTEMS
AQUASAFETM FLOW TEST
VERIFICATION
FORM
AquaSAFETM Flow Test Verification Form
Alliance
1 ; i Important:Installing contractor must submit this
Member ID: i `'1 j completed form.Failure to do so nullifies the
Company Name: t "v c s 3` !t:- itt system wan artyE-mail or fax completed form
to the Uponor Fire Safety Design Department
Contact: _)Bim. L -LC at technical.services@uponor.com or 952.997.1731,
.� Act l� -c� For questions,contact Uponor Technical Services at
Phone: 888.594.7725 or technical.services@uponor.com.
Fax: (1 I.-25c'{ .sBO _a Color of test orifice used: !3 i . ..
Job Name: $iti�1n +c 1�C �f +5 > Static pressure(not flowing)reading at incoming
Project Number: (et Di Or tens water supply into home or at main shutoff:
Job Address: 13 f t S Jtu Vlkcii�s i� �
Residual pressure(flowing)reading at incoming water
City: r[ ' ,i,4 supply into home or at main shutoff:
State,ZIP: g- I.2-
j
What time of day was the flow test taken?
For designs not provided by Uponor,complete the
following information. Flow test method used? LIBucket Flow Meter
Designer's Name: Flow test gpm: 5 f7wA
How many gallons of water did the design predict
Company: as required? (}'e4
Phone: Did the test meet or exceed design flow? Yes ❑No
Fax: Which sprinkler did you flow?Number: S
Is the warning sign permanently attached close to the Location of head: ` ' g{(r e w.-1
main shutoff valve? Yes ®No
Date left in service with all valves open: S•-S t t.
Was this system required by code?CAYes ❑No
Test Witnessed and Verified by:
.s Name '�nature Occupation Date
a
a
a
N
Additional Explanations and Notes
s
Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponoriusa.com
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