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FIRE SAFETY SYSTEMS
AQUASAFETm FLOW TEST
iVERIFICATION
AquaSAFE1M Flow Test Verification Form
Affiance Important:Installing contractor must submit this
Member ID: _ completed form.Failure to do so nullifies the
Company Name: ktI(jet vt{P R1l,y { a system warranty.E-mail or fax completed form
L -- to the Uponor Fire Safety Design Department
Contact: t 014 ,,, at technical.serviceseuponor.corn or 952.997.1731.
Phone-` s0g-111D- ?j1.19e.) For questions,contact Uponor Technical Services at
888.594.7726 or technical.seerviceseuponor.com.
Fax: i.-_ hI-t.'
/} ---- Color of test orifice used:
Job Name: Rive- (cArec,f
Static pressure(not flowing)reading at incoming
Project Number: _ I1 water supply into home or at main shutoff: CK
Job Address: /SD 13 S-14,) Ube
Residual pressure(flowing)reading at incoming water
City E,1 �t'f[
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supply into home or at main shutoff: 60
State,ZIP: Ore._ 4'17 ok3-',
= What time of day was the flow test taken? tl'IC�ci
For designs not provided by Uponor, complete the
following information. Flow test method used? 4 Bucket 3 Flow Meter
Designer's Name: _(tCL4t reoft.1 Flow test gpm: 'ig
Company: _ — — How many gallons of)ater did the design predict
CM3--
om^J Cgs as required? r
Phone: �j� Did the test meet or exceed design flow? 4 Yes 3 No
Fax: _
Which sprinkler did you flow?Number: U9
Is the warning sign permanently attached close to the
main shutoff valve? J Yes No , Location of head: Ca Yuy1G�l 17
f in1Sl,\ Date left in service with all valves open: tib1/1_8____
Was this system required by code?(if Yes No
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I Test Witnessed and Verified by:
N� K;rr��� Signature 0 cupati n Dat
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Additional Explanations and Notes
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? Uponor,Inc. Tel:800.321.4739
a 5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA
2 Web:www.uponor-usa.com