Fire Main Pre-Flush and Bag Test ACSA Approval Request Form Fire Main Pre-Flush and Bag Test ACSA Approval Request Date: * Contractor Name: * Contact Name: * Contact Phone: * Contact Email: * Name of Development / Building: * Address of Proposed Test: * Address of Proposed Test: Address of Proposed Test: Address of Proposed Test: City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Building Permit Number: * Fireline Size (required Flow Rate (GPM) for 10 FT/S Velocity): * 2" (100 GPM) 2.5" (150 GPM) 3" (220 GPM) 4" (390 GPM) 5" (610 GPM) 6" (880 GPM) 8" (1,560 GPM) 10" (2,440 GPM) 12" (3,520 GPM) Proposed Date of Pre-Flush: * Proposed Time of Pre-Flush: * 121234567891011 : 0030 AMPM Proposed Date of Bag Test (required County Inspector scheduling by Contractor): * Proposed Time of Bag Test (requires County Inspector scheduling by Contractor): * 121234567891011 : 0030 AMPM Description of Flow Measurement Technique by Contractor for Confirmation of Required Flow Rate: * Comments: If you are human, leave this field blank. Submit Δ