Report (Y)S! O,7 v C3 t-/7 U
r UP0010(
•
FIRE SAFETY SYSTEMS
AQUASAFFETM' FLOW TEST
VERIFICATION
•
AquaSAFEIM Flow Test Verification Form
Alliance
Important Installing contractor must submit this
Member ID: __ .— completed form.Failure to do so nullifies the
Company Name: _1
�^^C� ��wmn� _ system warranty.E-mail or fax completed form
Contact: _, (�( to the Uponor Fire Safety Design Department
at technical.services@uporwr com or 952 997.1731.
Phone- �( L(GL For questions,contact Uponor Technical Services at
-_2 ___ 888 594 7726 or technkal services�yponorcom.
Fax:
Job Name: 21 rr,v-v
Color of test orifice used:
/ �� � Static pressure(not flowing)reading at incoming
Project Number: =� so water supply into home or at main shutoff:
Job Address: 3 , ' I r
. � —
City: -1 Yc1`t`!\ Residual pressure(flowing)reading at incoming water
supply into home or at main shutoff: _ —_
State,ZIP: 21")(g.)
For designs not provided by Uponor, complete the What time of day was the flow test taken? '-_
following information. Flow test method used? ,Ai Bucket D Flow Meter
•Designer's Name: b SE a , —._ Flow test gpm:_�'�
Company: _ _ �, •, _^ _ . How many gallons of water did the design predict
Phone: as required?—i1
Did the test meet or exceed design flow? 41 Yes Fax:
J No
Which sprinkler did you flow?Number H I
Is the warning sign permanently attached close to the
main shutoff valve? J Yes 4 No Location of head: j�'
t'lpj�}\
Fe
Was this system required by code? Yes 7 No Date left in service with all valves open: w ja fes_
E
2 Test Witnessed and Verified by:
Si. atur
Namam .t' �fl — a 1 Occupati n Da
'. t
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0
N
Additional Explanations and Notes
s1
A
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z Uponor,Inc. Tel:800.321.4739
s 5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA - Web:www,uponor.usa.com