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UOflO1: 00 8 t FIRE SAFETY SYSTEMS
AQUASAFETM FLOW TEST
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VERIFICATION
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FORM
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AquaSAFETM Flow Test Verification Form
Alliance /,,• Important:Installing contractor must submit this
Member ID: / Ct 7 completed form.Failure to do so nullifies the
system warranty.E-mail or fax completed form
Company Name: ;(,e/I r4/r/r►�"'� 'I• L/,C: to the Uponor Fire Safety Design Department
Contact: D us -t L PIA &-e, at technical.services@uponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: r-0.3 "i-7 s---es) 1 S
888.594.7726 or echnicalservices@uponor.com.
Fax: 5—a 3. 6 J``1-z-$'1 1 Color of test orifice used: i"14
Job Name: t.:44f+40vvr iZii36.6 al/ $ Static pressure(not flowing)reading at incoming
Project Number: .ZOU`17 i= Z3'7.Z. water supply into home or at main shutoff: -7 Z--
Job Address: /..?..r,44.:). s LI 'fie 4 L.v,
Residual pressure(flowing)reading at incoming water
City: '77 t 4 tZ D supply into home or at main shutoff: 6-'-)
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State,ZIP: G/Z
What time of day was the flow test taken? 3.« '/""9
For designs not provided by Uponor,complete the
following information. Flow test method used?.,a1 Bucket ❑Flow Meter
Designer's Name:
Flow test gpm:. 1`-1,r
Company: How many gallons of water did the design predict
as required? /
Phone: Did the test meet or exceed design flow?)ei Yes ❑No
Fax: Which sprinkler did you flow?Number: N"T
Is the warning sign permanently attached close to theLocation of head: �,.�C��ir.,
main shutoff valve? .$Yes ❑No
Date left in service with all valves open: it//A
Was this system required by codeLe Yes ❑No
11Test Witnessed and Verified by:
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Name Signature Occupation Date
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Additional Explanations and Notes
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LL Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
s Apple Valley,MN 55124 USA Web:www.uponor-usa.com
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