Report (35) , ,• ,fif::' It PA.5 7 9.01 6 60 4-1q2
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uponor
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FIRE SAFETY SYSTEMS
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AQUASAFETM FLOW TEST
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VERIFICATION
FORM
AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name: ,41
system warranty.E-mail or fax completed form
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to the Uponor Fire Safety Design Department
Contact: 10 la-4-Of c1,4,-6,I/N at technical.serviceseuponor.rom or 952.997.1731.
Phone: 903-91.1- 3 9/6 For questions,contact Uponor Technical Services at
888.594.7726 or technical.services@uponor.com.
Fax:
Color of test orifice used: 6 raha
Job Name: ()kr-le/rat e...
Static pressure(not flowing)reading at incoming
Project Number: Li C-).• IL-'7 water supply into home or at main shutoff: 5 )-
Job Address: 1 12)-(o) cts)At."4,4f51.,"rrQ.c.r
Residual pressure(flowing)reading at incomingwater
City: *10747)tA 7n2e-4111 supply into home or at main shutoff:
State,ZIP: (9.19-- 3
What time of day was the flow test taken?
For designs not provided by Uponor,complete the
Flow test method used? 'kg-tJ icket Flow Meter
following information,
Designer's Name: ereAir 14,DmAe: Flow test gpm: .5.
Company:
How many gallons of water did the design predict
'proof'
as required? l7Phone: , 55-4-- ) - 5. 3° Did the test meet or exceed design flow? a/es Li No
Fax:
Which sprinkler did you flow?Number: H..I
1 , Is the warning sign permanently attached close to the Location of head: V2*.k.reovA.)-
1 ,r''.V" "i main shutoff valve? Li Yes : '..-No
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Date left in service with all valves open: , . ,
Was this system required by code?CKes J No
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Test Witnessed and Verified by:
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Name - Signature Occupation Date
!)'30
Additional Explanations and Notes
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Uponor,Inc. Tel:800321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com