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FIRE SAFETY SYSTEMS
AQUASAFETM FLOWTEST
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. M VERIFICATION
FORM
AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form. Failure to do so nullifies the
n/ system warranty. E-mail or fax completed form
Company Name: R.)//c)1� Pit,r+ �� to the Uponor Fire Safety Design Department
Contact: C`L 1304,1 ivIAA-J at technicalservices@uponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: S-d 3 Ca 7 S>/ 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used: N A c
Job Name: p0,,,bA ic Static pressure(not flowing)reading at incoming
IN 3a 7
N Project Number: 5 ^-i water supply into home or at main shutoff: y&' ,
� 5 co+ 3
Job Address: Pia 9 7 ,S+-.1 it.,,‘?/i-
Residual pressure (flowing)reading at incoming water
C) City: 7,'6"(2 6 supply into home or at main shutoff: 3 y f' .
UV
,V State,ZIP:
What time of day was the flow test taken? caZ pi"'.
For designs not provided by Uponor, complete the ,k�,,�
Flow test method used? ❑Bucket ENFlow Meter
following information.Designer's Name: P, ci € / ��u,,.✓c)c'�`,,,,-J Flow test gpm: 3
Company: 0 PO/4 CYG How many gallons of water did the design predict
as required? 1 3
Phone: 9`i a 517 1 7 / Did the test meet or exceed design flow? l Yes ❑No
Fax: Which sprinkler did you flow? Number: /t f1
is the warning sign permanently attached close to the Location of head:
main shutoff valve? ❑Yes ❑No
�/' Date left in service with all valves open: 9I—'/'�U
i�Was this system required by code? Yes No
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Test Witnessed and Verified by:
5. Name p Occupation Date
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Additional Explanations and Notes
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F Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
I Apple Valley,MN 55124 USA Web:www.uponor-usa.corn
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