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,certh. uponor
FIRE SAFETY SYSTEMS
f t AQUASAFETM FLOW TEST
A. 0 � VERIFICATION•
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E` FORM
AquaSAFETM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
I A f� system warranty.E-mail or fax completed form
Company Name. t to the Uponor Fire Safety Design Department
Contact: C941ittl .Tha at technical.services@uponor.com or 952.997.1731.
2 �— For questions,contact Uponor Technical Services at
Phone:�,p7 4 Z-- 31'1 888.594.7726 or technical.services@uponor.com.
Fax: Color of test orifice used:
Job Name. ���r��,�c�c 4,1-11,,,---7---6-1-44,e Static pressure(not flowing)reading at incoming_
Project Number:( ,..OL O I Z- , water supply into home or at main shutoff: 8"-L
Job Address: 24-7 Sts )67•.,
Residual pressure(flowing)reading at incomm water
City: I supply into home or at main shutoff: (146-
State,
State,ZIP: 0
What time of day was the flow test taken? l D
For designs not provided by Uponor,complete the
following information. Flow test method used? Bucket ❑Flow Meter
Designer's Name: Flow test gpm: 3
Company: How many gallons of water did the design predict
as required? 13
Phone: Did the test meet or exceed design flow? V1Yes ❑No
Fax: Which sprinkler did you flow?Number:
Is the warning sign permanently attached close to the Location of head: P_ ri— 51- eL-
main shutoff valve? ❑Yes ❑No
Date left in service with all valves open:
Was this system required by code?❑Yes ❑No
Test Witnessed and Verified by:
Name Signature Occupation Date
11711711- -corlA3' 0‘404,-7-- ,L.47/44Z4
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Additional Explanations and Notes °-
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O_
Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com