Fire Main Pre-Flush and Bag Test ACSA Approval Request Form

Date: *

Contractor Name: *

Contact Name: *

Contact Phone: *

Contact Email: *

Name of Development / Building:

Address of Proposed Test: *

Address of Proposed Test:

City

State/Province

Zip/Postal

Building Permit Number: *

Fireline Size (required Flow Rate (GPM) for 10 FT/S Velocity): *

Proposed Date of Pre-Flush:

Proposed Time of Pre-Flush:

:

Proposed Date of Bag Test (required County Inspector scheduling by Contractor):

Proposed Time of Bag Test (requires County Inspector scheduling by Contractor):

:

Description of Flow Measurement Technique by Contractor for Confirmation of Required Flow Rate: *

Comments: