Report y 1 si2vt7 00>. °3
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E SAFETY SYSTEMS
� AQ ° SAFE''" FLOW TEST
VERIFICATION
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a F".E " Row Test Vezificatio , Form
Affiance Important kat/Aliso . • •,* must*Molt .
Member ID: form. to do so endears the
Comps Name _ /h zet or fart cornetist:ad fate
to tilts I ,
Contact: rax"- i'stth ri^a*..*.
- .. at .,° 01152'997j731.
done: r 1,edutical Services
"'Li c)2. ..3e j 4z> � . at:
Fax: - Color of test orifice -, : re'
Job Nestle: '(...l.t.r--14�*;e`r,L.wr static fro Omt x ,.. .)readfrig at incom
Prt :ct Number water sup*into at math shutoff: iff /
Job 13!Jul Sw '� luxCw-c..
ai pressure( reading at irtcoming water
City '1 k 9 cat'd simply home or., ri shutoff:
State,ZIP:
What time of day was , flow test tit?
Row-kir dsisigts not wielded by Upormr,corris)lete test method ,. .r;
0 Flow Meter
fedlowyntg i+dOtmatiort _
� �l /',411's Name. 4 Raw test /c, °• ;,,
Company e^r11 4. Now many of ' did the design predict
'S'�2.-' '3' •-"5.
as requited 0
Phone: 9
Did the test meet or J;• •design flow? CI Yes C7 Na
Which er did ?Number . 10
i Is the ararriing sitjri permanently attached closet€,the f
r-t-�► meas ire? 0 Yes jO iota head �y��
Date left in service all valves open: ` `.24'-
Was tl'is system rued by code?ilitYes 0 Nu
Test IAtnessed and xVerified try:`
i Name ...41e a, ";i�. Date
ix fir.tt --� ' i, .- "' `-_ 1`)
I
Additional boierstiors and Notes
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donee',#nc,, y Tel:800.321.739
St Beit Itix952.997.1731.
ppie Vaney,MN 55124 USA ilk w wupanowua.co n