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FIRE SAFETY SYSTEMS
AQUASAFETM' FLOW TEST
VERIFICATION
AquaSAFE' Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name: fit 114;1'bG-C Plit,lr �' system warranty.E-mail or fax completed form
nn —— to the Uponor Fire Safety Design Department
Contact: hr3X-6 IDXJ) at technical.services@uponor.com or 952.997.1731.
Phone-'_ CO 9- �/ ,� - e) For questions,contact Uponor Technical Services at
888.594.7726 or technical.services@uponor.com.
Fax: y�
_ - Color of test orifice used: S1 wR
Job Name: 12i14"( 1Ctivw.
Static pressure(not flowing)reading at incoming
Project Number: _ Le 1' water supply into home or at main shutoff:
Job Address: / am Sw //171.41'
nn Residual pressure(flowing)reading at incoming water
City: I t til OYN
supply into home or at main shutoff: t'O
State,ZIP: 6111 cf)C )
What time of day was the flow test taken? II'�G
For designs not provided by Uponor, complete the
following information. //�� Flow test method used? Bucket 3 Flow Meter
Designer's Name: _ 13p t`e�K4-'-(a. Flow test gpm:_'I R
Company: _ (,t�Q j z Or How many gallons of water did the design predict
ti,... — — as required? 17
Phone: 93 ' 99)-5?36
Did the test meet or exceed design flow? Yes :7 No
Fax: _ L
Which sprinkler did you flow?Number: R I
Is the warning sign permanently attached close to the €Jtr,�,�
main shutoff valve? -1 Yes No Location of head:
ort FI'nl's� .,
Date left in service with all valves open: I`Ilkli
Was this system required by code?IlYes 3 No
Test Witnessed and Verified by:
Na e Si nater-
Zrtr �(� � 9 Oc/cyupatiof� Date ,ji
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Additional Explanations and Notes
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Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com