VAMC AUGUSTA UPTOWN 05-11-2023.pdf

MEDICAL GAS

TESTING & INSPECTION

VAMC AUGUSTA UPTOWN

AUGUSTA, GA

1-800-872-8992 www.evergreenmedical.com

05/11/2023

MEDICAL GAS INSPECTION REPORT

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

Medical Facility:

City, State:

Medical Gas Contact Name:

Medical Gas Contact Dept:

Inspection Dates(s):

Territory MGR Josh Jenkins ASSE 6030 CREDENTIAL: 00062565

Lead Technician(s) Brandon Charbonneau ASSE 6030 CREDENTIAL: 12366457

Evergreen Medical Services, Inc. in accordance with applicable NFPA & CMS codes and standards has evaluated the medical piping systems indicated in this report. These systems have been found to be within applicable guidelines except as noted within this report. Any deficiencies cited are based on the most current applicable edition of NFPA 99.

Conflicts may occur when different editions of NFPA 99 have been adopted by different AHJs, and compliance occurs with one edition but not the other. Changes made to newer editions of NFPA 99 are done so to improve the system's quality, integrity, fire resistance, effectiveness, durability, and safety. Dependent on the opinion of the

AHJ(s), the newer code edition is generally acceptable as equivalent or superior to an older version(s).

Per NFPA 99 an existing system that is not in strict compliance with the applicable codes may continue to be used as long as it is not a distinct hazard to safety. Fire/Explosion hazards, labeling, manifold enclosures, medical air usage, & maintenance codes apply to new & existing facilities.

Information recorded on this report represent findings on the indicated evaluation date(s) only. Any action taken in response to recommendations included in this report should be recorded on the appropriate pages. This report should not be copied unless in entirety.

- Particulate Contaminants . . Page(s) 53

- Gaseous Contaminants . . . Page(s) 54

Section 7 - Source EQPT Summary . . Pg(s) 55

- Source Equipment . . . Page(s) 56-58

Section 8 - Annex . . . Page(s) 59-60

Section 5 - Outlets & Inlets . . . Page(s) 33-49

- Outlets & Inlets Inventory . . . Page(s) 50

JAMES JARRIEL

FACILITIES ENGINEERING

05/11/2023

VAMC AUGUSTA UPTOWN

AUGUSTA, GA

Outlets & Inlets Deficiencies . . Page(s) 51

Section 6 - Contaminants

- System Dew Point . . . Page(s) 52

REPORT CONTENTS

Section 1 - Systems Overview . . . . Page(s) 3-5

Section 2 - Master Alarms . . . . Page(s) 6-8

- Master Alarm Inventory . . . Page(s) 9

- Master Alarm Deficiencies . . . Page(s) 10

Section 3 - Area Alarms . . . Page(s) 11-15

- Area Alarm Inventory . . . Page(s) 16

- Area Alarm Deficiencies . . . Page(s) 17-24

Section 4 - Zone Valves . . . . Page(s) 25-29

- Zone Valve Inventory . . . Page(s) 30

- Zone Valve Deficiencies . . . Page(s) 31-32 www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

GAS SYSTEMS OVERVIEW

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

MASTER ALARMS/SIGNALS (EACH SIGNAL COUNTED INDIVIDUALLY)

AREA ALARMS (EACH SYSTEM GAS COUNTED AS SEPARATE ALARM)

ZONE VALVES (EACH SYSTEM GAS COUNTED INDIVIDUALLY)

Total Master Alarm Signals

Quantity of Passing Master Alarm Signals

Quantity of Deficient Master Alarm Signals

Total Quantity of Zone Valves has remained the same from previous medical gas systems inspection.

Total Quantity of Master Alarm Signals has remained the same from previous medical gas systems inspection.

Total Quantity of Area Alarms has remained the same from previous medical gas systems inspection.

Total Area Alarms

Quantity of Passing Area Alarms

Quantity of Deficient Area Alarms

Total Zone Valves

Quantity of Passing Zone Valves

Quantity of Deficient Zone Valves

96.2%

3.8% Quantity of

Passing Area

Alarms

Quantity of

Deficient Area

Alarms

100.0%

0.0% Quantity of

Passing Zone

Valves

Quantity of

Deficient Zone

Valves

100.0%

0.0% Quantity of

Passing Master

Alarm Signals

Quantity of

Deficient Master

Alarm Signals www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

GAS SYSTEMS OVERVIEW

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

OUTLETS, INLETS & MANUFACTURED ASSEMBLIES

SYSTEM DEW POINT

PARTICULATE CONTAMINANTS

Total Quantity of Outlets, Inlets and Manufactured Assemblies has remained the same from previous medical gas systems inspection.

Total Outlets & Inlets

Quantity of Passing Outlets/Inlets

Quantity of Deficient Outlets/Inlets

Quantity of Passing Test Sites

Quantity of Deficient Test Sites

Total Particulate Contaminant Test Sites

Quantity of Passing Test Sites

Quantity of Deficient Test Sites

The Test Sites are selected in order to represent System Dew

Point in both high-use and low-use areas for the systems tested.

The Test Sites are selected in order to represent Particulate

Contaminants in both high-use and low-use areas for the systems tested.

Total Dew Point Test Sites

100.0%

0.0% Quantity of

Passing

Outlets/Inlets

Quantity of

Deficient

Outlets/Inlets

100%

0% Quantity of

Passing Test

Sites

Quantity of

Deficient Test

Sites

100%

0% Quantity of

Passing Test

Sites

Quantity of

Deficient Test

Sites www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

GAS SYSTEMS OVERVIEW

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

GASEOUS CONTAMINANTS

SOURCE EQUIPMENT

Quantity of Deficient Test Sites

Total Gaseous Contaminants Test Sites

Quantity of Passing Test Sites

The Test Sites are selected in order to represent Gaseous

Contaminants in all separate distribution and source systems.

Total Source Systems

Quantity of Passing Source Systems

Quantity of Deficient Source Systems

Total Quantity of Source Equipment has remained the same from previous medical gas systems inspection.

100%

0% Quantity of

Passing Test

Sites

Quantity of

Deficient Test

Sites

100%

0% Quantity of

Passing Source

Systems

Quantity of

Deficient Source

Systems www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

MASTER ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

M a ster A la rm P a n el

L o ca tio n

If M u ltip le P a n els

P er L o ca tio n

(e.g . "E n g in eerin g P a n el #

S y stem G a s

M a n u fa ctu rer

M o d el

C o n d itio n

M o n ito red

S w itch o r S o u rce L o ca tio n

S et P o in t

U n it o f M ea su re

In itia tin g

D ev ice

W irin g

P a n el

L a b elin g

O th er

C o m p o n en t C o n d itio n

1 Switchboard 4E 116 O2 Amico A2M Liquid Level Low O2 Bulk Enclosure 45 inH2O ✓ ✓ ✓ ✓ ✓ PASS

2 Switchboard 4E 116 O2 Amico A2M Reserve in Use O2 Bulk Enclosure 80 PSI ✓ ✓ ✓ ✓ ✓ PASS

3 Switchboard 4E 116 O2 Amico A2M Reserve Pressure Low O2 Bulk Enclosure 1400 PSI ✓ ✓ ✓ ✓ ✓ PASS

4 Switchboard 4E 116 O2 Amico A2M High Line Pressure Basement Hall 60 PSI ✓ ✓ ✓ ✓ ✓ PASS

5 Switchboard 4E 116 O2 Amico A2M Low Line Pressure Basement Hall 40 PSI ✓ ✓ ✓ ✓ ✓ PASS

6 Switchboard 4E 116 MA Amico A2M High Line Pressure Mech Room 60 PSI ✓ ✓ ✓ ✓ ✓ PASS

7 Switchboard 4E 116 MA Amico A2M Low Line Pressure Mech Room 40 PSI ✓ ✓ ✓ ✓ ✓ PASS

8 Switchboard 4E 116 MA Amico A2M High Dew Point Temp Mech Room 35 ºF ✓ ✓ ✓ ✓ ✓ PASS

9 Switchboard 4E 116 MA Amico A2M High CO Level Mech Room 10 PPM ✓ ✓ ✓ ✓ ✓ PASS

10 Switchboard 4E 116 MA Amico A2M Lag Compressor Running Mech Room 80 PSI ✓ ✓ ✓ ✓ ✓ PASS

11 Switchboard 4E 116 VAC Amico A2M Low Line Pressure Mech Room 12 inHg ✓ ✓ ✓ ✓ ✓ PASS

12 Switchboard 4E 116 VAC Amico A2M Lag Pump in Use Mech Room 16 inHg ✓ ✓ ✓ ✓ ✓ PASS

MASTER ALARMS: LOCATION & SPECIFICATION FUNCTION & CONDITION

www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

MASTER ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

M a ster A la rm P a n el

L o ca tio n u ltip le P a n els

P er L o ca n g in eerin g P a n el #

S y stem G a s

M a n u fa ctu rer

M o d el

C o n d itio n

M o n ito red

S w itch o r S o u rce L o ca tio n

S et P o in t

U n it o f M ea su re

In itia tin g

D ev ice

W irin g

P a n el

L a b elin g

O th er

C o m p o n en t C o n d itio n

MASTER ALARMS: LOCATION & SPECIFICATION FUNCTION & CONDITION

13 Police O2 Amico A2M Liquid Level Low O2 Bulk Enclosure 45 inH2O ✓ ✓ ✓ ✓ ✓ PASS

14 Police O2 Amico A2M Reserve in Use O2 Bulk Enclosure 80 PSI ✓ ✓ ✓ ✓ ✓ PASS

15 Police O2 Amico A2M Reserve Pressure Low O2 Bulk Enclosure 1400 PSI ✓ ✓ ✓ ✓ ✓ PASS

16 Police O2 Amico A2M High Line Pressure Basement Hall 60 PSI ✓ ✓ ✓ ✓ ✓ PASS

17 Police O2 Amico A2M Low Line Pressure Basement Hall 40 PSI ✓ ✓ ✓ ✓ ✓ PASS

18 Police MA Amico A2M High Line Pressure Mech Room 60 PSI ✓ ✓ ✓ ✓ ✓ PASS

19 Police MA Amico A2M Low Line Pressure Mech Room 40 PSI ✓ ✓ ✓ ✓ ✓ PASS

20 Police MA Amico A2M High Dew Point Temp Mech Room 35 ºF ✓ ✓ ✓ ✓ ✓ PASS

21 Police MA Amico A2M High CO Level Mech Room 10 PPM ✓ ✓ ✓ ✓ ✓ PASS

22 Police MA Amico A2M Lag Compressor Running Mech Room 80 PSI ✓ ✓ ✓ ✓ ✓ PASS

23 Police VAC Amico A2M Low Line Pressure Mech Room 12 inHg ✓ ✓ ✓ ✓ ✓ PASS

24 Police VAC Amico A2M Lag Pump in Use Mech Room 16 inHg ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

MASTER ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

M a ster A la rm P a n el

L o ca tio n u ltip le P a n els

P er L o ca n g in eerin g P a n el #

S y stem G a s

M a n u fa ctu rer

M o d el

C o n d itio n

M o n ito red

S w itch o r S o u rce L o ca tio n

S et P o in t

U n it o f M ea su re

In itia tin g

D ev ice

W irin g

P a n el

L a b elin g

O th er

C o m p o n en t C o n d itio n

MASTER ALARMS: LOCATION & SPECIFICATION FUNCTION & CONDITION

Refrigeration Shop 1D

O2 Amico A2M Liquid Level Low O2 Bulk Enclosure 45 inH2O ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

O2 Amico A2M Reserve in Use O2 Bulk Enclosure 80 PSI ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

O2 Amico A2M Reserve Pressure Low O2 Bulk Enclosure 1400 PSI ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

O2 Amico A2M High Line Pressure Basement Hall 60 PSI ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

O2 Amico A2M Low Line Pressure Basement Hall 40 PSI ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

MA Amico A2M High Line Pressure Mech Room 60 PSI ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

MA Amico A2M Low Line Pressure Mech Room 40 PSI ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

MA Amico A2M High Dew Point Temp Mech Room 35 ºF ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

MA Amico A2M High CO Level Mech Room 10 PPM ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

MA Amico A2M Lag Compressor Running Mech Room 80 PSI ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

VAC Amico A2M Low Line Pressure Mech Room 12 inHg ✓ ✓ ✓ ✓ ✓ PASS

Refrigeration Shop 1D

VAC Amico A2M Lag Pump in Use Mech Room 16 inHg ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

MASTER ALARM INVENTORY

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

MASTER ALARM SIGNALS

BY SYSTEM GAS:

15 15 0 0 0 6 0 0 0

TOTAL

MASTER ALARM

PANELS

TOTAL MASTER ALARM SIGNALS:

MANUFACTURER

(Or Current Owner )

MODEL MASTER ALARM PANEL DESCRIPTION

O

M A

N

O

N

C O

V A

C

W A

G D

IA

O th er

Amico A2M Gray Cover with Red LED Indicators 15 15 0 0 0 6 0 0 0

TOTAL

MASTER ALARM

PANELS

MASTER ALARMS BREAKDOWN (*EACH MASTER ALARM SIGNAL COUNTED AS SEPARATE ALARM BY SYSTEM GAS BELOW) www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

MASTER ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

QTY

DEFICIENT

QTY

CORRECTED

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

0 0

N) Labeling: No Source Location

I) Panel: Incorrect Power Source

J) Panel: Incorrect Location

K) Panel: No Signal in Place (Local Alarm Only)

L) Panel: No Signal in Place (No Initiating Device/Wiring)

M) Labeling: System Gas

Connect Alarm to Life Safety Branch

Move Alarm Panel to a Proper Location

Wire Initiating Device to Master Alarm Panel(s)

Add Signal/Signal Components to Master Alarm System

Verify and Relabel System Gas

Verify and Relabel Source Location

D) Wiring: Not Independent to at Least (2) Master Panels

E) Wiring: Shared Common Conductors

F) Wiring: Not Protected

G) Panel: Visual and/or Audible Function Failed

H) Panel: Power Failure

MASTER ALARM DEFICIENCIES OVERVIEW

DEFICIENCY DESCRIPTION

A) Initiating Device: Incorrect Location

B) Initiating Device: Improper Set Point

C) Initiating Device: None in Place

CORRECTIVE ACTION NEEDED

Move Initiating Device to Proper Location and/or Install Demand Check

Adjust Alarm Set Point

Install Initiating Device

O) Labeling: No Condition Monitored

P) Other:

Verify and Relabel Condition Monitored

N/A

TOTALS:

Rewire Panels Independently to Initiating Device

Rewire Panels Independently to Initiating Device With Correct Number of

Conductors

Protect Master Alarm Wiring

Repair/Replace Annunciator Module/Alarm Panel

Repair/Replace Power Supply www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d in g

(P o sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

A la rm L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

C o m p o n en t C o n d itio n

1 4E Serves No Outlets O2 Beacon P0321 50 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NOT IN USE

2 4E Serves No Outlets MA Beacon P0321 25 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NOT IN USE

3 4E Serves No Outlets VAC Beacon P0321 27 12 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NOT IN USE

4 3F 3F109 & 3F148 O2 Beacon P0321 50 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

5 3F 3F109 & 3F148 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

6 3F 3F109 & 3F148 VAC Beacon P0321 28 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

7 3E 3E108 & 109 O2 Beacon P0321 50 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

8 3E 3E108 & 109 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

9 3E 3E108 & 109 VAC Beacon P0321 30 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ M FAIL

10 3G 3G 104 & 143 O2 Beacon P0321 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

11 3G 3G 104 & 143 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

12 3G 3G 104 & 143 VAC Beacon P0321 26 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

13 3D 3D 115, 120, 121, 132, 139, 150, 151 O2 Beacon P0321 47 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

14 3D 3D 115, 120, 121, 132, 139, 150, 151 MA Beacon P0321 54 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

15 3D 3D 115, 120, 121, 132, 139, 150, 151 VAC Beacon P0321 23 12 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

AREA ALARMS: LOCATION & SPECIFICATION FUNCTION AND CONDITION

www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

A la rm L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

C o m p o n en t C o n d itio n

AREA ALARMS: LOCATION & SPECIFICATION FUNCTION AND CONDITION

16 3C 3C106-110, 115-116, 3C133-136 & 141 O2 Amico A2A 48 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

17 3C 3C106-110, 115-116, 3C133-136 & 141 MA Amico A2A 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

18 3C 3C106-110, 115-116, 3C133-136 & 141 VAC Amico A2A 26 12 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

19 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

O2 Beacon P0321 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

20 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

21 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

VAC Beacon P0321 28 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

22 2A Dental Clinic O2 Beacon P0321 48 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

23 2A Dental Clinic VAC Beacon P0321 12 ✓ ✓ ✓ ✓ ✓ J K✓ ✓ FAIL

24 2C 2C109, 2C110, 2C125, 133, 134, 135, 136, 141 O2 Beacon P0321 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

A la rm L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

C o m p o n en t C o n d itio n

AREA ALARMS: LOCATION & SPECIFICATION FUNCTION AND CONDITION

25 2C 2C109, 2C110, 2C125, 133, 134, 135, 136, 141 MA Beacon P0321 53 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

26 2C 2C109, 2C110, 2C125, 133, 134, 135, 136, 141 VAC Beacon P0321 29 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

27 2D 2D115, 153 O2 Beacon P0321 45 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

28 2D 2D115, 153 MA Beacon P0321 50 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

29 2D 2D115, 153 VAC Beacon P0321 29 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

30 2E 2E108 & 145 O2 Beacon P0321 48 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

31 2E 2E108 & 145 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

32 2E 2E108 & 145 VAC Beacon P0321 29 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

33 Opp 1D 141 1D140-1D143, 1D148 O2 Powerex MedTouch 45 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

34 Opp 1D 141 1D140-1D143, 1D148 MA Powerex MedTouch 51 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

35 Opp 1D 141 1D140-1D143, 1D148 VAC Powerex MedTouch 24 12 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

36 Opp 1D 120 Future Use O2 Powerex MedTouch 45 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

37 Opp 1D 120 Future Use MA Powerex MedTouch 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

38 Opp 1D 120 Future Use VAC Powerex MedTouch 21 12 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

36 1C

1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145

O2 Beacon P0321 47 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

A la rm L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

C o m p o n en t C o n d itio n

AREA ALARMS: LOCATION & SPECIFICATION FUNCTION AND CONDITION

37 1C

1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145

MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

41 1C

1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145

VAC Beacon P0321 28 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

42 1B 1B114, 117, 119, 120, 121, 122, 129, 130 O2 Beacon P0321 54 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

43 1B 1B114, 117, 119, 120, 121, 122, 129, 130 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

44 1B 1B114, 117, 119, 120, 121, 122, 129, 130 VAC Beacon P0321 27 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

45 1E 1E 120, 121, & 126-129 O2 Powerex MedTouch 45 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

46 1E 1E 120, 121, & 126-129 MA Powerex MedTouch 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

47 1E 1E 120, 121, & 126-129 VAC Powerex MedTouch 24 12 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

48 1E AA #2 1E 146-149, & 151-155 O2 Powerex MedTouch 45 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

49 1E AA #2 1E 146-149, & 151-155 MA Powerex MedTouch 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

50 1E AA #2 1E 146-149, & 151-155 VAC Powerex MedTouch 28 12 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

51 GC GC104, 145, 146, 147 O2 Beacon P0321 48 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED

52 GC GC104, 145, 146, 147 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARMS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

A la rm L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

C o m p o n en t C o n d itio n

AREA ALARMS: LOCATION & SPECIFICATION FUNCTION AND CONDITION

53 GC GC104, 145, 146, 147 VAC Beacon P0321 27 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ REPAIRED www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARMS INVENTORY

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

TOTAL AREA ALARM SIGNALS

BY SYSTEM GAS:

18 17 0 0 0 18 0 0 0

TOTAL

AREA ALARM

PANELS

TOTAL AREA ALARM SIGNALS:

MANUFACTURER

(Or Current Parent

Company )

MODEL AREA ALARM DESCRIPTION

O

M A

N

O

N

C O

V A

C

W A

G D

IA

O th er

Amico A2A Gray Cover with Digital Pressure 1 1 0 0 0 1 0 0 0

Beacon P0321 White with Murphy gauges-"Area Line Press. Alm" 13 12 0 0 0 13 0 0 0

Powerex MedTouch Tritech MedTouch / "Powerex" branding 4 4 0 0 0 4 0 0 0

TOTAL

AREA ALARM

PANELS

AREA ALARMS BREAKDOWN (EACH AREA ALARM SIGNAL COUNTED AS SEPARATE ALARM BY SYSTEM GAS BELOW) www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

AREA ALARM DEFICIENCIES OVERVIEW

ACTION NEEDED

Adjust Set Points to +/-20% Operating Pressure

Move Transducers to Correct Side of Zone Valve

QTY

CORRECTED

DEFICIENCY DESCRIPTION

A) Alarm Set Points: Incorrect High and/or Low Alarm Set Point(s)

QTY

DEFICIENT

Connect Alarm to Life Safety Branch

Repair/Replace Module or Defective Transducer

Label Area Monitored

Label Gas System Monitored

Inaccurate Gauge Pressure

Install Demand Check

Repair/Recalibrate/Replace Transducer

Move Alarm to Appropriate Location

Install Area Alarm & Transducer

Repair/Replace Annunciator Module / Ribbon Cable / Alarm Panel

Repair/Replace Power Supply

G) Panel Function: Visual and/or Audible Alarm Function Failure

H) Panel Function: Power Failure

I) Panel Function: Incorrect Power Source

J) Module Function: Module Display Blank or Error Message

K) Labeling: Area Monitored Labeling Missing/Incorrect

B) Transducer Location: Incorrect Transducer Location

C) Transducer Location: No Demand Check

D) Transducer Function: Incorrect Gas Pressure Displayed

E) Alarm Location: Improper Alarm Panel Location

F) Alarm Location: No Alarm in Place

L) Labeling: Gas System Monitored Not Labeled

M) Other: 1 www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

P a n el L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

4 3F 3F109 & 3F148 O2 Beacon P0321 50 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

5 3F 3F109 & 3F148 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

6 3F 3F109 & 3F148 VAC Beacon P0321 28 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

7 3E 3E108 & 109 O2 Beacon P0321 50 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

/O R

C O

R R

E C

T

IV

E A

C T

IO

N

P lea se D a te, D escrib e A ctio

T a ken

R efer to

W o rk

O rd er if A p p lica b le

DEFICIENCY CODE

AREA ALARM DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

DEFICIENT AREA ALARM LOCATION

TOTALS: 2 32

www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

P a n el L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

R R

E C

T

IV

E A

C T

IO

lea se D a te, D escrib e A ken

R efer to

W o rk

O rd er if A p p lica b le

DEFICIENCY CODE

AREA ALARM DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

DEFICIENT AREA ALARM LOCATION

8 3E 3E108 & 109 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

9 3E 3E108 & 109 VAC Beacon P0321 30 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ M M) Other (See Deficiency

Page for Detail)

10 3G 3G 104 & 143 O2 Beacon P0321 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

11 3G 3G 104 & 143 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

12 3G 3G 104 & 143 VAC Beacon P0321 26 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

P a n el L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

R R

E C

T

IV

E A

C T

IO

lea se D a te, D escrib e A ken

R efer to

W o rk

O rd er if A p p lica b le

DEFICIENCY CODE

AREA ALARM DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

DEFICIENT AREA ALARM LOCATION

19 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

O2 Beacon P0321 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

20 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

21 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

VAC Beacon P0321 28 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

22 2A Dental Clinic O2 Beacon P0321 48 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

23 2A Dental Clinic VAC Beacon P0321 12 ✓ ✓ ✓ ✓ ✓ J K✓ ✓

J) Module Function: Module

Display Blank or Error

Message www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

P a n el L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

R R

E C

T

IV

E A

C T

IO

lea se D a te, D escrib e A ken

R efer to

W o rk

O rd er if A p p lica b le

DEFICIENCY CODE

AREA ALARM DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

DEFICIENT AREA ALARM LOCATION

24 2C 2C109, 2C110, 2C125, 133, 134, 135, 136, 141 O2 Beacon P0321 49 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓

K) Labeling: Area Monitored

Labeling Missing/Incorrect

25 2C 2C109, 2C110, 2C125, 133, 134, 135, 136, 141 MA Beacon P0321 53 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓

K) Labeling: Area Monitored

Labeling Missing/Incorrect

26 2C 2C109, 2C110, 2C125, 133, 134, 135, 136, 141 VAC Beacon P0321 29 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓

K) Labeling: Area Monitored

Labeling Missing/Incorrect

27 2D 2D115, 153 O2 Beacon P0321 45 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

28 2D 2D115, 153 MA Beacon P0321 50 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

P a n el L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

R R

E C

T

IV

E A

C T

IO

lea se D a te, D escrib e A ken

R efer to

W o rk

O rd er if A p p lica b le

DEFICIENCY CODE

AREA ALARM DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

DEFICIENT AREA ALARM LOCATION

29 2D 2D115, 153 VAC Beacon P0321 29 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

30 2E 2E108 & 145 O2 Beacon P0321 48 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

31 2E 2E108 & 145 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

32 2E 2E108 & 145 VAC Beacon P0321 29 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

36 1C

1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145

O2 Beacon P0321 47 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

P a n el L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

R R

E C

T

IV

E A

C T

IO

lea se D a te, D escrib e A ken

R efer to

W o rk

O rd er if A p p lica b le

DEFICIENCY CODE

AREA ALARM DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

DEFICIENT AREA ALARM LOCATION

37 1C

1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145

MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

41 1C

1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145

VAC Beacon P0321 28 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

42 1B 1B114, 117, 119, 120, 121, 122, 129, 130 O2 Beacon P0321 54 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓

K) Labeling: Area Monitored

Labeling Missing/Incorrect

43 1B 1B114, 117, 119, 120, 121, 122, 129, 130 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓

K) Labeling: Area Monitored

Labeling Missing/Incorrect

44 1B 1B114, 117, 119, 120, 121, 122, 129, 130 VAC Beacon P0321 27 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓

K) Labeling: Area Monitored www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

AREA ALARM DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

A la rm P h y sica l L o ca tio n

A rea

/Z o n e M o n ito red

S y stem G a s

M a n u fa ctu rer

M o d el

P ressu re R ea d sitive in P

S I/N eg a tive in In

/H g

H ig h P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

L o w P ressu re A la rm

S ettin g

(P o sitive in P

S I/N eg a tive in In

/H g

A la rm S et P o in ts

T ra n sd u cer L o ca tio n

T ra n sd u cer F u n ctio n

P a n el L o ca tio n

P a n el F u n ctio n

M o d u le F u n ctio n

L a b elin g

O th er

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

R R

E C

T

IV

E A

C T

IO

lea se D a te, D escrib e A ken

R efer to

W o rk

O rd er if A p p lica b le

DEFICIENCY CODE

AREA ALARM DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

DEFICIENT AREA ALARM LOCATION

51 GC GC104, 145, 146, 147 O2 Beacon P0321 48 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

52 GC GC104, 145, 146, 147 MA Beacon P0321 52 60 40 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored

Labeling Missing/Incorrect

53 GC GC104, 145, 146, 147 VAC Beacon P0321 27 12 ✓ ✓ ✓ ✓ ✓ ✓ K✓ ✓ K) Labeling: Area Monitored www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

FUNCTION AND CONDITION

Z V

B P h y sica l L o ca tio n

R o o m s o r A rea S erv ed

S y stem G a s

M a n u fa ctu rer

B a ll

G a te/G lo b e

G a u g e P ressu re A ccu ra cy

G a u g e

G en era l C o n d itio n

L a b elin g

L ea k s

L o ca tio n

O th er

C o m p o n en t C o n d itio n

1 4E Serves No Outlets O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ S✓ NOT IN USE

2 4E Serves No Outlets MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NOT IN USE

3 4E Serves No Outlets VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NOT IN USE

4 3F 3F109 & 3F148 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

5 3F 3F109 & 3F148 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

6 3F 3F109 & 3F148 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

7 3E 3E108 & 109 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

8 3E 3E108 & 109 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

9 3E 3E108 & 109 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

10 3G 3G 104 & 143 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

11 3G 3G 104 & 143 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

12 3G 3G 104 & 143 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

13 3D 3D 115, 120, 121, 132, 139, 150, 151 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

14 3D 3D 115, 120, 121, 132, 139, 150, 151 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

15 3D 3D 115, 120, 121, 132, 139, 150, 151 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

ZONE VALVES: LOCATION & SPECIFICATION

www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

FUNCTION AND CONDITION

Z V

B P h y sica l L o ca tio n

R o o m s o r A rea S erv ed

S y stem G a s

M a n u fa ctu rer

B a ll

G a te/G lo b e

G a u g e P ressu re A ccu ra cy

G a u g e

G en era l C o n d itio n

L a b elin g

L ea k s

L o ca tio n

O th er

C o m p o n en t C o n d itio n

ZONE VALVES: LOCATION & SPECIFICATION

16 3C 3C106-110, 115-116, 3C133-136 &

O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

17 3C 3C106-110, 115-116, 3C133-136 &

MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

18 3C 3C106-110, 115-116, 3C133-136 &

VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

19 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

20 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

21 2B

2B114, 115, 120, 121, 122, 123, 124, 125, 130, 131, 132, 150, 126, 143, 149, 148, 141, 142, 147

VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

22 2A 2A217, 218, 219, 220 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

23 2A 2A217, 218, 219, 220 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

24 2A 2A204, 206, 207, 208 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

25 2A 2A204, 206, 207, 208 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

26 2A 2A201, 203 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

27 2A 2A201, 203 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

FUNCTION AND CONDITION

Z V

B P h y sica l L o ca tio n

R o o m s o r A rea S erv ed

S y stem G a s

M a n u fa ctu rer

B a ll

G a te/G lo b e

G a u g e P ressu re A ccu ra cy

G a u g e

G en era l C o n d itio n

L a b elin g

L ea k s

L o ca tio n

O th er

C o m p o n en t C o n d itio n

ZONE VALVES: LOCATION & SPECIFICATION

28 2A 203 N2O Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ NOT IN USE

29 2A 203 N2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ NOT IN USE

30 2A 2A 199, 198, 197 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

31 2A 2A 199, 198, 197 N2O Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

32 2C 2C 141 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

33 2C 2C 141 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

34 2C 2C 141 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

35 2D 2D115, 153 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

36 2D 2D115, 153 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

37 2D 2D115, 153 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

38 2E 2E108 & 145 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

39 2E 2E108 & 145 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

40 2E 2E108 & 145 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

41 1F 1F116, 139, 150, 151 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

42 1F 1F116, 139, 150, 151 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

FUNCTION AND CONDITION

Z V

B P h y sica l L o ca tio n

R o o m s o r A rea S erv ed

S y stem G a s

M a n u fa ctu rer

B a ll

G a te/G lo b e

G a u g e P ressu re A ccu ra cy

G a u g e

G en era l C o n d itio n

L a b elin g

L ea k s

L o ca tio n

O th er

C o m p o n en t C o n d itio n

ZONE VALVES: LOCATION & SPECIFICATION

43 1F 1F116, 139, 150, 151 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

44 Opp 1D 141 1D140-1D143, 1D148 MA Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

45 Opp 1D 141 1D140-1D143, 1D148 O2 Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

46 Opp 1D 141 1D140-1D143, 1D148 VAC Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

47 Opp 1D 120 Future Use MA Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

48 Opp 1D 120 Future Use O2 Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

49 Opp 1D 120 Future Use VAC Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

47 1C 1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

48 1C 1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

52 1C 1C110, 111, 112, 113, 118, 128, 129, 137, 138, 139, 140, 145 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

53 1B 1B114, 117, 119, 120, 121, 122, 129, O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

54 1B 1B114, 117, 119, 120, 121, 122, 129, MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

55 1B 1B114, 117, 119, 120, 121, 122, 129, VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

56 1A 1A159 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

FUNCTION AND CONDITION

Z V

B P h y sica l L o ca tio n

R o o m s o r A rea S erv ed

S y stem G a s

M a n u fa ctu rer

B a ll

G a te/G lo b e

G a u g e P ressu re A ccu ra cy

G a u g e

G en era l C o n d itio n

L a b elin g

L ea k s

L o ca tio n

O th er

C o m p o n en t C o n d itio n

ZONE VALVES: LOCATION & SPECIFICATION

57 1A 1A159 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

58 1A 1A159 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

59 1E 1E 120, 121, & 126-129 O2 Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

60 1E 1E 120, 121, & 126-129 MA Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

61 1E 1E 120, 121, & 126-129 VAC Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

62 1E ZVB #2 1E 146-149, & 151-155 O2 Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

63 1E ZVB #2 1E 146-149, & 151-155 MA Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

64 1E ZVB #2 1E 146-149, & 151-155 VAC Powerex ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

65 GC GC104, 145, 146, 147 O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

66 GC GC104, 145, 146, 147 MA Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

67 GC GC104, 145, 146, 147 VAC Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVES INVENTORY

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

TOTAL ZONE VALVES BY SYSTEM GAS: 23 19 2 1 0 22 0 0 0

TOTAL

ZONE VALVE

BOXES

TOTAL ZONE VALVES

MANUFACTURER

(Or Current Owner )

VALVE

TYPE

ZONE VALVE DESCRIPTION

O

M A

N

O

N

C O

V A

C

W A

G D

IA

O th er

Beacon Ball 1/4 Turn Ball Valve 19 15 2 1 0 18 0 0 0

Powerex Ball 1/4 Turn Ball Valve 4 4 0 0 0 4 0 0 0

ZONE VALVES BREAKDOWN (EACH SYSTEM GAS COUNTED AS SEPARATE ZONE VALVE)

TOTAL

ZONE VALVE

BOXES

www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVE DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

ZONE VALVE DEFICIENCIES OVERVIEW

QTY

CORRECTED

QTY

DEFICIENT

Rebuild if Possible or Replace Leaking Valve

Re-install Gauge Using Oxygen-Safe Sealant (Replacement of Valve May be Necessary)

Move Valve to Visible and Accessible Location

Move Valve to Compliant Location

Install Zone Valve

Label All Required Components with Non-Standard Pressure

Update Label to Include System Gas

Update Label to Include Warning Verbiage

Verify if Rooms/Area is Served by an Existing Zone Valve (Installation

Necessary if Rooms/Area is not Currently Served by a Zone Valve)

Rebuild if Possible or Replace Leaking Valve

R: Location: No Valve in Place

Verify the valve is controlling correct gas

0 1TOTALS:

S: Other: 0

Q: Location: Improper Location

DEFICIENCY DESCRIPTION

A: Gauge: Inaccurate Pressure Reading

B: Gauge: Incorrect Scale Range

C: Gauge: No Gauge in Port

D: Gauge: On Source Side of Valve

N: Leak: Gas Passes Through Valve When Closed

P: Location: Hidden or Not Accessible

M: Leak: External Leak

J: Labeling: Missing System Gas

K: Labeling: Missing Warning Verbiage

L: Labeling: Rooms/Area not Attributed a Zone Valve

O: Leak: Gauge Connection Leaks

I: Labeling: Missing Non-Standard Pressure Verbiage

ACTION NEEDED

Replace Gauge

Install Gauge With Correct Scale Range

Install Gauge

Repipe Valve So Gauge is Downstream of Valve

Replace Handle

Replace Window

Verify Rooms/Area Served and Relabel

Verify Rooms/Area Served and Relabel (Repiping or Decommissioning

Valve May Be Necessary)

E: General Condition: Missing/Broken Handle

F: General Condition: Missing/Broken Window

G: Labeling: Inaccurate Rooms/Area Served

H: Labeling: Labeled as if in Series www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

ZONE VALVE DEFICIENCIES

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

L o ca

(O /S

O u tsid e & p p

O p p o site)

R o o m s o r A r ea

S erv ed

S y stem

G a s

M a n u fa ctu rer

B a ll

G a te/G lo b e

G a u g e P ressu re R e a d sitive in P

S I / N eg a tive in "H g

G a u g e

G en er a l C o n d itio n

L a b elin g

L ea k s

L o ca tio n

O th er

1 4E Serves No Outlets O2 Beacon ✓ ✓ ✓ ✓ ✓ ✓ ✓ S✓ S) Other (See Deficiency Page for Detail)

D E

F

IC

IE

N

C Y

D E

T A

IL

A

N D

R R

E C

T

IV

E A

C T

IO

lea se D a te, D escrib e A ken

R efer to W o rk

O rd er if A p p lica b le

DEFICIENT VALVE LOCATION

DEFICIENCY

CODE

ZONE VALVE DEFICIENCIES BREAKDOWN (BY ITEM NUMBER)

www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

OUTLETS & INLETS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

1 3F 109 O2 Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

2 3F 109 MA Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

3 3F 109 VAC Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

4 3F 148 O2 Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

5 3F 148 MA Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

6 3F 148 VAC Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

7 3E 108 O2 Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

8 3E 108 MA Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

9 3E 108 VAC Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

10 3E 109 O2 Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

11 3E 109 MA Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

12 3E 109 VAC Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

13 3G 104 O2 Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

14 3G 104 MA Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

15 3G 104 VAC Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

16 3G 143 O2 Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

17 3G 143 MA Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

18 3G 143 VAC Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

19 3D 151 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

20 3D 151 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

21 3D 151 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

22 3D 150 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

23 3D 150 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

24 3D 150 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

L o ca tio n

O th er

G a s C o n cen tra tio n

C o m p o n en t C o n d itio n

O p era tio n a l F lo w

S ta tic P ressu re

FUNCTION AND CONDITIONOUTLETS & INLETS: LOCATION & SPECIFICATION

G en era l C o n d itio n

L ea k s

L a b elin g

M o d el

P o sitio n

/S ty le

A rea o r Z o n e

R o o m

, B ed o r O u tlet #

(In ven to ry ta ken clo ckw ise a ro u n d ro o m

, fro m to to b tto m a n d /o r left to rig h t)

S y stem G a s

M a n u fa ctu rer www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

OUTLETS & INLETS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

L o ca tio n

O th er

G a s C o n cen tra tio n

C o m p o n en t C o n d itio n

O p era tio n a l F lo w

S ta tic P ressu re

FUNCTION AND CONDITIONOUTLETS & INLETS: LOCATION & SPECIFICATION

G en era l C o n d itio n

L ea k s

L a b elin g

M o d el

P o sitio n

/S ty le

A rea o r Z o n e

R o o m

, B ed o r O to ry ta ken clo ckw ise a ro u n d ro o m

, fro m to tto m a n d /o r left to rig h t)

S y stem G a s

M a n u fa ctu rer

25 3D 139 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

26 3D 139 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

27 3D 139 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

28 3D 132 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

29 3D 132 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

30 3D 132 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

31 3D 121 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

32 3D 121 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

33 3D 121 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

34 3D 120 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

35 3D 120 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

36 3D 120 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

37 3D 115 O2 Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

38 3D 115 MA Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

39 3D 115 VAC Beacon DIA III Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

40 3C 106 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

41 3C 106 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

42 3C 106 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

43 3C 107 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

44 3C 107 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

45 3C 107 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

46 3C 108 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

47 3C 108 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

48 3C 108 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

OUTLETS & INLETS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

L o ca tio n

O th er

G a s C o n cen tra tio n

C o m p o n en t C o n d itio n

O p era tio n a l F lo w

S ta tic P ressu re

FUNCTION AND CONDITIONOUTLETS & INLETS: LOCATION & SPECIFICATION

G en era l C o n d itio n

L ea k s

L a b elin g

M o d el

P o sitio n

/S ty le

A rea o r Z o n e

R o o m

, B ed o r O to ry ta ken clo ckw ise a ro u n d ro o m

, fro m to tto m a n d /o r left to rig h t)

S y stem G a s

M a n u fa ctu rer

49 3C 109 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

50 3C 109 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

51 3C 109 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

52 3C 109 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

53 3C 109 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

54 3C 109 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

55 3C 110 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

56 3C 110 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

57 3C 110 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

58 3C 115 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

59 3C 115 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

60 3C 115 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

61 3C 115 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

62 3C 115 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

63 3C 115 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

64 3C 116 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

65 3C 116 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

66 3C 116 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

67 3C 116 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

68 3C 116 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

69 3C 116 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

70 3C 133 O2 Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

71 3C 133 MA Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS

72 3C 133 VAC Amico O-DIA Wall (Recessed) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ PASS www.evergreenmedical.com © 2021 Evergreen Medical Services, Inc. - VER 1.3 Corporate Office: 1-800-872-8992

OUTLETS & INLETS

Medical Gas and Vacuum Systems Inspection/Testing

VAMC Augusta Uptown

Augusta, GA

L o ca tio n

O th er

G a s C o n cen tra tio n

C o m p o n en t C o n d itio n

O p era tio n a l F lo w

S ta tic P ressu re

FUNCTION AND CONDITIONOUTLETS & INLETS: LOCATION & SPECIFICATION

G en era l C o n d itio n

L ea k s

L a b elin g

M o d el

P o sitio n

/S ty le

A rea o r Z o n e

R o o m

, B ed o r O to ry ta ken clo ckw ise a ro u n d ro o m

, fro m to tto m a n d /o r left to rig h t)

S y stem G a s

M a n u fa ctu rer

73 3C 134 O2 Amico O-DIA Wall (Recessed)…