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FIRE SAFETY SYSTEMS
13 If 0 k */ l- i AQUASAFErm FLOW TEST
VERIFICATION
FORM
AquaSAFETM Flow Test Verification Form
AllianceImportant Installing contractor must submit this
Member ID: % 10'1 completed form.Failure to do so nullifies the
�`�,ZyvtI system warranty.E-mail or fax completed form
Company Name: (TY-a.t.A7tt
y to the Uponor Fire Safety Design Department
Contact: Tizr 14-tot1-e at technical.services@upawr.com or 951997.1731.
Phone: SC)3 {-AGI O - 1 (0 3 For questions,contact Uponor Technical Services at
888.594.7726 or technicalservices@uponor.com.
Fax: 91I-25 0 3SOF Color of test orifice used: B ltc�C
Job Name: 5L 4%tfrt(l K iC4, ok- 14 1 Static pressure(not flowing)reading at incominL p�-�
Project Number: 11 07 l) F v no 2, water supply into home or at main shutoff:
Job Address: 31 D S I,) Y:O -<_k.I n
Residual pressure(flowing)reading at incoming water
City: 'icf� �� supply into home or at main shutoff:
State,ZIP: Oit fir C( 2:2-14
J What time of day was the flow test taken?
For designs not provided by Uponor,complete the
following information. Flow test method used? `Bucket l Flow Meter
Designer's Name: Flow test gpm:
Company: How many gallons of water did the design predict
as required?
Phone:
Did the test meet or exceed design flow? LI Yes Li No
Fax: Which sprinkler did you flow?Number: ZS
Is the warning sign permanently attached close to the Location of head: '60A(DOWN LI
main shutoff valve? ❑Yes Cl No
Date left in service with all valves open: tv—1"1 (rJ
Was this system required by code?LI Yes Ll No
3 •
Test Witnessed and Verified by:
Name nature Occupation Date Date
J .LM 6 I v't_�C.( e.c.��`,�' .=..)..�.� (a11 v k1/
sAdditional Explanations and Notes
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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