Report (28) IrLS II 7,0i 6 -- co
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, 37
FIRE SAFETY SYSTEMS
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VERIFICATION
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
warranty.systE-mail or fax completed form
Company Name: if .a a AL, 441 _____ to theenitipanor Fire Safety Design Department
atFrtechtticaain,sse
Contact: pci,v4 -Ty,sV,„ r.„. A.
'cones,!".tiir:nro"rlUirn95icafS9L1c73es1;t
Phone: S03 'y92-,39.94) 888.° 1:194.7726or tedmicatservitesetilmiumcont
Fax.
Color of test-onfice used:
Job Name: ;Vitt 1-1.4rirrikr-4.- Static pressure(not flowing)reading at incornin
Project Number: -c-c7 - g A 4
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water supply into home or at main shutoff: 't
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Job Address: 13 7e.7-57 :St il''''t 5,
Residual pressure(flowing)reading at incoming water
City: -779c4d
supply into home or at main shutoff: Sr
State,ZIP: '72ZZ ----------------------
What time of day was the flow test taken?
For designs not provided by Uponor,complete the
following information. Flow test method used?A Bucket i Flow Meter
Designer's Name:
, if Flow test pm:
i -60.0 '
Company: How
m7gallons of water did the design predict
14,64149( ..._ ID
Phone: 9c,;2-9197—.57,,,."
Did the test meet or exceed design flow?.6Y es U No
Fax:
Which sprinkler did you fin ?Number: 1/-3
ill/
.. , .„,...... Is the warning sign permanently attached close to the Location of head,
*fir tri. "...."'Jr main shutoff valve? 1J Yes *No
Date left in service with all valves open:
Was this system required by code?„1/10Yes ID No
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Test Witnessed and Verified by:
N , Signature Occupation Date
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3.,.. . Additional Explanations and Notes
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Upcmor,Inc. Tel fltX)321.4739
5925 148th Street West Fax:952.9971731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com
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