Report (5) �.. M5T2o161- COI3� 111193 sw 164r" AVE'
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? °.k FIRE SAFETY SYSTEMS
' AQUASAFETM FLOW TEST
` , VERIFICATION
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FORM
`Y '' '.AquaSAFE"TM Flow Test Verification Form
Alliance Important:Installing contractor must submit this
Member ID: completed form.Failure to do so nullifies the
( � system warranty.E-mail or fax completed form
Company Name: i'1 r jli fy to the Uponor Fire Safety Design Department
Contact: 6ri,f4h f(„ljy,tA5 at technicalserviceseuponor.com or 952.997.1731.
For questions,contact Uponor Technical Services at
Phone:
- `1T 2.-- 3` 40 888.594.7726ortechnical.services@/uponor,com.
Fax: /� //�� Color of test orifice used: l_,t�'1
Job Name: P� It`4 a Kr✓e-- /r .4.(Static pressure(not flowing) reading at incoming )
Project Number: ,2-5-is-- - 00�4i r1 water supply into home or at main shutoff: LT2e5,
Job Address: /71N' -Sty) 1(7 l tl -e--
Residual pressure(flowing) reading at incoming water
City: supply into home or at main shutoff: L/rf"r5.1
State,ZIP:
What time of day was the flow test taken? /OITL,...
For designs not provided by Uponor,complete the Flow test method used? U Bucket ❑Flow Meter
following information.
Designer's Name: Flow test gpm: r3
Company: How many gallons of water did the design predict
as required?
Phone: Did the test meet or exceed design flow? Yes ❑No
Fax: Which sprinkler did you flow? Number: Z
Is the warning sign permanently attached close to the Location of head:sibe .P:otar vez_ 5/...1
main shutoff valve? U Yes ❑No
Date left in service with all valves open:
Was this system required by code?❑Yes ❑No
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Test Witnessed and Verified by:
Name Signature Occupation Date
WA-7r 7'7- f � /3/ylI1
9
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N
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Additional Explanations and Notes k '
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Uponor,Inc. Tel:800.321.4739
5925 148th Street West Fax: 00.32 .4739
Apple Valley, MN 55124 USA Web:www.uponor-usa.com