Report (34) (fl $T 2017 — Doi VO
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AQ I SAFElm FLOW TEST
VERIFICATION
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i Row Test-Verificatio ! Foy
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Mem II): completed form to ds se tedWies the
Carry N : J *t L e t. i't,,--.4) sv Marr' or floc fare►
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Contact W.R #s MiillaroeLat . •E E' . '. 3
For Phone:'501- 7'L't mar
Fax Ct#u of tat orifice
Job ane: 1 C.wC.d" E e.. t�
Std preswrlt#tiat • °,E • ming at role
Project
Numberwater�into at main shutoff:
` Job Address: / O ..St...i i4>
} �•ua t s; reading at i ing water
City: i�.. e-ie supply into home or at shutoff: �13.
Stag 21P 1 �
What time of day was• flow test taken? r
for desitirs not prey ed by Upanca`,complete the
following information, Flout test method used"•' t3isclost d flow Meter
Disigoser's ► 'f .,,,` i. Flow test gprm 45-
i.- tion many g� of r did the design predit
as required?
Phone: 7 56 Did the test meet or a< a.design flow?,, Yes i No
fes' MO sp<k►kier tfid you'' ?Nuleer' 4
is the pennanently attached dose to the tacaticxe of h
1 -` f j' mainrtoff ? O Yes i a--'""'.- L 1,4t
Was this required +ride? Q No Date in service <<a g}:�men:
~Test Witnessed and Verified by
Name i ... A. s is,ar� DateY f
Adder bipitinettens and Notes
o
Upaner Inc. Tel:800,321.4739
5925 1 %most Welt Fax 952.997.1731 .
Apple Veyy.MN 55124 USA