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z FIRE SAFETY SYSTEMS
: AQUASAFETM FLOW TEST
w VERIFICATION
FORM
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AaSETM Flow Test Verification Form
Affiance Important:installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name: A 1I`04411c6 PikwtrJ a, system warranty.E-mail or fax completed form
,1 to Up Safety Design Department
Contact Fete,+ Dt5 v at technical.servicesluporaw.con or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: cos-1114.- 3y°i o 8813.594.7726 or technicai.services@uponor.com.
Fax: /� Color of test orifice used: SS
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Job Name: Vef Terrace, Static pressure(not flowing)reading at incoming
Project Number: Li- water supply into home or at main shutoff: 102_
Job Address: t3-5- f�
Residual pressure(flowing)reading at incgming water
City: rl)rti1O supply into home or at main shutoff: St
State,ZIP: OR) cr)4.,
What time of day was the flow test taken? 13'44)
For designs not provided by Uponor,complete the Flow test method used? �ucket U Flow Meter
Designees
following information. kl rte^
Flow test gpm: -�
Designer's Name:
Company: s i/bI` How many gallons of water did the design predict
as P-oJo�)- 5 Sao as required? 17 ��
Phone: / d Did the test meet or exceed design flow? LYYes 0 No
Fax: Which sprinkler did you flow?Number: //. 5
Is the warning sign permanently attached close to the Location of head: Pi �—
Tr1�-1 main shutoff valve? ❑Yes Lino
S`" �7
Date left in service with all valves open:
Was this system required by code?iYes Cl No
2 Test Witnessed and Verified by:
Name Signator Occup ion Date
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Additional Explanations and Notes
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Uponor,Inc. Tei:800.321.4739
5925 Street West Fax 952.997.1731
Apple Valley MN 55124 USA Web:www ra.com
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