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° 4' kFIRE SAFETY SYSTEMS
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'',7;91.1ilt,\ ..! AQUASAFET"' FLOW TEST
_Ait ', VERIFICATION
\\ €� ;E..,; FORM
AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
I, :._ I system warranty. E-mail or fax completed form
Company Name. l I GS• /64.1-110 to the Uponor Fire Safety Design Department
Contact: C9""' ikbLv4.y'' at technical.services@uponor.com or 952.997.1731.
a For questions,contact Uponor Technical Services at
Phone' 'j �'1'r2 3'L1 O
888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: Lag
Job Name. Cut— P-',-1/c0erf4"Static pressure(not flowing)reading at incoming
Project Number: 111 1 083(73- O 1water supply into home or at main shutoff: S2_
L
Job Address: 11D.,5 X1/.1 1 t' '
Residual pressure(flowing)reading at incoming water
City: supply into home or at main shutoff: 6-
State,ZIP:
What time of day was the flow test taken? jOi4+-rte
For designs not provided by Uponor,complete the
following information. Flow test method used?laBucket ❑Flow Meter
13 Designer's Name Flow test gpm:
Company: How many gallons of water did the design predict
as required? l
Phone. Did the test meet or exceed design flow? /AYes ❑No
Fax: Which sprinkler did you flow? Number: /6
Is the warning sign permanently attached close to the Location of head: l"'/'11.//I P>e--(1-1-4)(9Gi-
main shutoff valve? ❑Yes ❑No
Date left in service with all valves open:
Was this system required by code?❑Yes ❑No
Test Witnessed and Verified by:
Name SignatureA - ,-� Occupation ����y
Date
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= Additional Explanations and Notes f 6 / r
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Uponor,Inc. Tel:800321.4739
5925 148th Street West Fax:952 997.1731
i Apple Valley,MN 55124 USA Web:www.uponor-usa.com