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, ,„ FIRE SAFETY SYSTEMS
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AQUASAFETM FLOW TEST
VERIFICATION
FORM
AquaSAFErM Flow Test Verification Form
Affiance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name: 4tri;.4,..k & 4system warranty.E-mail or fax completed form
to the Uponor Fire Safety Design Department
Contact: (a,w1,, ty..e-S at technical,serviceseuponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone: Se). -'141 - 3` /O 888.594.7726 or techni al.serviceseuponor.com.
Fax: p "' Color of test orifice used:
Job Name: at " 1ht""`i rei`z, Static pressure(not flowing)reading at incoming
Project Number: 3.1.<75-Pcc) water supply into home or at main shutoff:
Job Address: Iq/to j(te.1241rLe.
Residual pressure(flowing)reading at incoming later
City: supply into home or at main shutoff: (45 ,
State, ZIP:
What time of day was the flow test taken? /0 4(4,
For designs not provided by Uponor, complete the
following information. Flow test method used? tLtBucket L]Flow Meter
Designers Name: Flow test gpm:
Company: How many gallons of water did the design predict
as required? 13
Phone: Did the test meet or exceed design flow? Zkyes 0 No
Fax: Which sprinkler did you flow?Number: If•Z
Is the warning sign permanently attached close to the Location of head: Rae).- 4.12,0&_ skia
main shutoff valve? ' Yes '%t No
Date left in service with all valves open:
Was this system required by code?41.Yes 0 No
Test Witnessed and Verified by:
fi Name Signatur Occupation Date
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Additional Explanations and Notes
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Uponor,Inc. Tel:800.321.4739
5925148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com
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