Report (8) ;i M5-12011- 3�
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• Uponor
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FIRE SAFETY SYSTEMS
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AQUASAFETM FLOW TEST
VERIFICATION
FORM
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AquaSAFE' Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name: 14 l �� �� �'� system warranty.E-mail or fax completed form
J to the Uponor Fire Safety Design Department
Contact:l t fl,,& at technicalserviceseuponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: ' 1/2_ 3410 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: 6.v-en/
Job Name: L..c 1 4sc 6e Static pressure(not flowing) reading at incoming
Project Number: 3 2.5 75 P oc9,-1 water supply into home or at main shutoff: S a-
iL
Job Address: /r/5 J'V ! l7 ' ArYv—
Residual pressure(flowing) reading at incoming water
City: supply into home or at main shutoff: V SW
State, ZIP:
What time of day was the flow test taken? 10 9I-r-,
For designs not provided by Uponor, complete the
following information. Flow test method used? Z8ucket U Flow Meter
Designer's Name: Flow test gpm: l�j
Company: How many gallons of water did the design predict
as required?
Phone: Did the test meet or exceed design flow? tat Yes U No
Fax: Which sprinkler did you TG flow?�1 Number: 2—
Is the warning sign permanently attached close to the Location of head: 7 `F`{eac4y- '%L i,L 51-Q
main shutoff valve? U Yes U No
Date left in service with all valves open:
Was this system required by code?)k1 Yes ❑No
Test Witnessed and Verified by:
Name Signature Occupation Date
Additional Explanations and Notes k 6
8A
Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com
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