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ARE SAFETY SYSTEMS
AQUASAFE" FLOW TEST
VERIFICATION
FORM
P .� rn STavITI-0011`1
, ' '114 r �
.14. TM
AquaSAFE Flow Test Verification Form
Alliance important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
� . b system warranty.E-mail or fax completed form
Company Name: i 64 40 1 a
el to the Uponor Fire Safety Design Department
Contact: 9.thrJr s es._ at technical.servicesluponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: -elci 2--3y90 988,594.7726 or technicatservices@uparor.com.
Fax: Color of test orifice used: liSrtas
Job Name: 2;VAC TdlCce tat Static pressure(not flowing)reading at incomin
Project Number: 1111111W water supply into home or at main shutoff: 0
Job Address: _/317 c' cy1Ac.n:Z•c,�-G4'
Residual pressure(flowing)reading at incomin water
City: 1790,4 supply into home or at main shutoff: .5-7.—
State,
State,ZIP: CKL "72:24.3 � �
What time of day was the flow test taken?
For designs not provided by Uponor,complete the Flow test method used?A Bucket 0 Flow Meter
following information.
Designer's Name: 'gre & `C.� yn Flow test gpm: I b ,
Company: U1.4?pt.%emir How many gallons of water did the design predict
as required? ) O
Phone: 9s-2.-44?—s33 p Did the test meet or exceed design flow? TIliPes ❑No
Fax: Which sprinkler did you flow?Number: Al. /0
Is the warning sign permanently attached close to the Location of head: 'BP�,2_
In ic.►? 1# -7 main shutoff valve? ❑Yes allo
Date left in service with all valves open: 9-12.-1
�(i-T W i 5%-- Was this system required by code?!tall Yes 0 No
I
Test Witnessed and Verified by:
L
"__ Name''I Sig Occup i Date
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Additional Explanations and Notes
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gi Uponor,Inc. Tel:800.321.4739
1 5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com