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

Today's Date(Required)

Contractor Name(Required)

Contact Name(Required)

First Last

Contact Phone(Required)

Contact Email(Required)

Name of Development / Building(Required)

Address of Proposed Test(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Building Permit Number(Required)

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

Proposed Date of Pre-Flush(Required)

Proposed Time of Pre-Flush(Required)

Proposed Date of Bag Test(Required)

Required County Inspector scheduling by Contractor

Proposed Time of Bag Test(Required)

Requires County Inspector scheduling by Contractor

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

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