Report (3) V� .1 �ST2Oid - 00 LO3
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:' FIRE SAFETY SYSTEMS
`zAQUASAFErM FLOW TEST
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VERIFICATION
':,:.'1:0.1,11; FORM
AquaSAFETM Flow Test Verification Form
Affiance 11.1 0Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
Company Name: �.USJ .1)(..,C system warranty.E-mail or fax completed form
to the Uponor Fire Safety Design Department
Contact: 0'0‘ii or% \k\ (J 1'n(3 at technical.services@uponor.com or 952.997.1731.
Phone: J\I_a1-.1Cl — -LI For questions,contact Uponor Technical Services at
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C� � 888.594.7726 or technical.services@uponor.com.[�
Fax: 7 �7 Color of test orifice used: 1 .0
Job Name: 110,.',S4 L _ Static pressure(not flowing)reading at incoming,. �}
Project Number: U\C�7ZJ
.3 z ] water supply into home or at main shutoff: `34.
Job Address:
Residual pressure(flowing)reading at incoming water
City: T I ter) supply into home or at main shutoff: "4
State,ZIP: O 12.
What time of day was the flow test taken? /COIZD
For designs not provided by Uponor, complete the
following information. Flow test method used $ucket LI Flow Meter
Designers Name: Flow test qpm:
Company: How many gallons of water did the design predict
as required? L3
Phone: Did the test meet or exceed design flow?,Yes C]No
Fax: Which sprinkler did you flow? Number: t� - rz
Is the warning sign permanently attached close to the Location of head: to� i3 4 v'Z rel
main shutoff valve? AYes U No
Date left in service with all valves open:
V.4 Was this system required by code?L]Yes J No
V
Test Witnessed and Verified by:
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Namei Signature Occupationi Date
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a' Additional Explanations and Notes
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Uponor,Inc. Tel:800,321.4739
5925 148th Street West Fax:952.997.1731
Apple Valley,MN 55124 USA Web:www.uponor-usa.com
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