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FIRE SAFETY SYSTEMS
A UASAFET" FLOW TEST
VERIFICATION
FORM
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AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form. Failure to do so nullifies the
J ` system warranty.E-mail or fax completed form
Company Name: Oi �1 u^A` ► to the Uponor Fire Safety Design Department
Contact: C./4 47 L #, at technical.services@uponor,com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: s(]3 Cp6 7 " l 2Fs 888.594.7726 or technical.services@uponor.com.
NFax: Color of test orifice used: eilhi/.--
Job Name: iOSh/}aLG— Static pressure(not flowing)reading at incoming
Project Number: 3as""7s-4
po 7 water supply into home or at main shutoff: xY
Job Address: 14-1a53'" 54--) )6)�l�L-
Residual pressure(flowing)reading at incoming water
City: �.�'i►t� supply into home or at main shutoff: 34/
N State,ZIP: 01J'�7—
What time of day was the flow test taken? iO t3t;.)
For designs not provided by Uponor,complete the ��,,��
following information. Flow test method used? ❑Bucket CEKIow Meter
/ / Flow test gpm: 13
Designer's Name: 12ALise a.Mvcisu
Company: N 4�-- How many gallon water did the design predict
as required? 1
Phone: 7 7 3/ Did the test meet or exceed design flow? 's ❑No
Fax: Which sprinkler did you flow?Number: II it
Is the warning sign permanently attached close to the Location of head: o2-
main shutoff valve? 0 Yes ❑No
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/ Date left in service with all valves open:
Was this system required by code?C es U No
Test Witnessed and Verified by:
na Occupation Date
0.
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Additional Explanations and Notes
8 Uponor,Inc. Tel:860.321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com