Report (3) 014( ' ,
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uponor
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VERIFICATION
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FORM
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AquaSAFE' Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name:
system warranty.E-mail or fax completed form
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to the Uponor Fire Safety Design Department
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Contact: ../- 4-v-4
K N1-1-4r.:11,4,‘,5 at technicalsemiceseunonor.com or 952.997.1731.
Phone: 3 (442. - 31.14--0 For questions,contact Uponor Technical Services at
888.5941726 or technicalsel;:rucionor.com.
Fax: Color of test orifice used:
Job Name: iZo;stut-ck evt- Ktv(...---tz,-0- Static pressure(not flowing)reading at incoming t
Project Number: 3)5-7S---r c9e9Li water supply into home or at main shutoff:
Job Address:
Residual pressure(flowing)reading at incoming water
City: supply into home or at main shutoff:
State,ZIP:
What time of day was the flow test taken? il-(9/4 . i
For designs not provided by Uponor, complete the
Flow test method used? )3.Bucket U Flow Meter
following information.
Flow test gpm: i.3.
Designer's Name:
How many gallons of water did the design predict
Company:
as required? /
Phone:
Did the test meet or exceed design flow? ,ittl Yes U No
Fax:
Which sprinkler did you flow? Number: /4.2
Is the warning sign permanently attached close to the Location of head: ..***--- j./ err 41—Art,",, -- c/tiit-Sr‘
main shutoff valve? U Yes U No
Date left in service with all valves open:
Was this system required by code?'.4.1 Yes U No
A
it I'D'6 Test Witnessed and Verified by:
iName Si. . urei - 05,cupation Date
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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:vvvvw.uponor-usa.com
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