DEPT OF VA COLUMBIA _ 7 SEP 2023 _ Medical Bulk Installation Inspection Form - MED - Rev 02-28-20.pdf

Bulk Installation Inspection Form - MED - Rev 02-28-20 Page 1

MEDICAL ANNUAL INSPECTION FORM Work Order #:

BULK SUPPLY SYSTEM Onsite Time (hr):

Travel Time (hr):

Inspection Date: Type of Inspection: Initial PM Customer Owned: Yes No

Customer: Account: Contact: Phone:

Address: City: State: ZIP:

Product: Location Type: Outdoor Indoor Courtyard

MAIN VESSEL INFORMATION

Tank Code: NB#: S/N: MFR Name:

Tank Size: MAWP: Rehab Date: MFR Year:

PSV Inlet Size: BD Inlet Size:

PSV Outlet Size: BD Outlet Size: Telemetry Type: Level Gauge Full: in.

PSV Set Point: BD Set Point: BAM# or FF#: Level Gauge Reorder: in.

RESERVE SUPPLY INFORMATION

Type: Cylinders Vessel For Reserve Cylinders, Qty: Cylinder Size: 9" x 55" 9" x 51"

For Reserve Vessel, Fill Out Information Below (Cylinder Height Excludes Valve)

Tank Code: NB#: S/N: MFR Name:

Tank Size: MAWP: Rehab Date: MFR Year:

PSV Inlet Size: BD Inlet Size:

PSV Outlet Size: BD Outlet Size: BAM Buddy: Yes No Level Gauge Full: in.

PSV Set Point: BD Set Point: Level Gauge Reorder: in.

1 OVERALL SITE CONDITION YES NO N/A NOTES/COMMENTS

1.1 Adequate trailer access, clear for safe delivery? (clear

line of sight, less than 25’ from trailer to fill valves)?

1.2 Adequate lighting for night time deliveries?

1.3 Site secured, fenced, and gates are locked?

1.4 Vessel and system is protected where exposed to

vehicle impact by bollards or other approved means?

1.5 Site has adequate ventilation or mitigation (vents

captured, etc.) if indoor or courtyard installation?

1.6 Adequate and safe access to service equipment? (3'

around vessel and other equipment)

1.7 Pipe supports anchored, pipe clamps tight, and unistrut

stand plastic caps installed?

1.8 Vessel, vaporizers, and equipment anchored?

1.9 Vessel and equipment concrete pad is in good condition

(no serious spalling, cracks, frost heaves, etc.)

1.10 Site has adequate drainage?

Bulk Installation Inspection Form - MED - Rev 02-28-20 Page 2

1.11 Pressure relief devices installed between block valves

and discharge in a safe direction?

1.12 Electrical equipment and conduit in good condition (no

signs of damage, labeled, etc.)?

1.13 System piping and components leak checked and free

of leaks?

1.14 Overall site condition is free of debris, chemical storage, combustibles, or other hazards?

1.15 Exposure distances comply with NFPA 55 and Airgas

Standards (NFPA Distances Table)?

1.16 Concrete off-load pad is installed, in good condition, and free of combustibles for O2 or N2O installations?

1.17 “No Smoking” signs posted for O2 or N2O installations?

1.18 Grounding system (if installed for O2 and N2O tanks, lightning protection, etc.) is in good condition and tight?

1.19 Telemetry system is functioning properly and solar

panel cleaned (if appl.)?

2 VESSEL CONDITION MAIN TANK RESERVE TANK NOTES/COMMENTS

(If no reserve tank, leave those columns unchecked) YES NO YES NO

2.1 Vessel cosmetic condition (paint, dirt, logo, etc.) is

adequate?

2.2 All required Airgas, NFPA, and warning decals are in

place, correct, and legible?

2.3 Tank code is legibly stenciled or labeled on vessel

(verify code if instructed)?

2.4 Vessel has pressure relief device on the fill line?

2.5 Pressure gauges are functional and legible?

2.6 Liquid level gauge is functional, legible, zero checked, and has "reorder" and "full" arrows?

2.7 Vessel has no signs of poor vacuum such as venting, cold spots, etc; (take vacuum reading if suspect)?

2.8 Fill connection correct, in good condition, and equipped

with dust or pressure cap?

2.9 Fill line check valve is installed & operationally checked by safely opening top fill valve to check back-flow?

2.10 Hose drain and full trycock valves are installed and

working properly?

2.11 Pressure building system tested and is operating

correctly at system set point per data label?

2.12 All valve handles are in good working order and valves

tagged properly?

2.13 Vessel has diverter assembly with dual PSVs/BDs?

Cycle to both sides to check flow and for any leaks.

2.14 Vessel PSVs are in good condition, legible, seals intact, and have no signs of weeping?

2.15 Vessel PSVs marked test date will be less than 5 years

old at time of next PM (capture test date)

Test Date:

2.16 Vessel PSVs are secure, free from obstruction, and

venting towards ground or safe location?

2.17 Vessel burst disks (BDs) visually inspected; set point < 150% tank MAWP, good condition, and not weeping?

Bulk Installation Inspection Form - MED - Rev 02-28-20 Page 3

EQUIPMENT INFORMATION

Main Vaporizer Type: Vap. Qty.: Vap. MFR: Vap. Model #:

Reserve Vap. Type: Vap. Qty.: Vap. MFR: Vap. Model #:

PCM Type: Liq Main/Liq Reserve Reg. Size: Reg. MFR: Reg. Model:

Liq Main/Cyl Reserve Delivery Pressure Set Point: Final Line PSV SetPt:

Auxiliary Manifold (Hyperbarics): Yes No Aux Manifold Set Point: Aux PSV Set Point:

Vaporizer Switching Manifold: Yes No Local Alarm Light Panel: Yes No

Other Equip. Notes:

3 EQUIPMENT CONDITION YES NO N/A NOTES/COMMENTS

3.1 Piping material and/or insulation is correct for the

service and in good working condition?

3.2 Process vaporizers at least 50% free of ice build up?

3.3 Vaporizer switching (if installed) verified for proper

operation?

3.4 Vaporizers are protected with thermal PSV and

inspected for set point, orientation, and condition?

3.5 Line regulators are inspected and checked for proper

operation and set point?

3.6 Final line PSV inspected and is in good condition, legible, and has no signs of weeping?

4 MEDICAL SYSTEM REQUIREMENTS YES NO N/A NOTES/COMMENTS

4.1 Bulk system alarm contacts are wired to the facility?

4.2 Discussed with facility their requirements to test

alarms?

4.3 Main vessel low level alarm signal works correctly? Set Point:

4.4 Reserve-in-use alarm signal works correctly? Set Point:

4.5 Reserve vessel low pressure alarm or reserve cylinders

low pressure alarm works correctly? Set Point:

4.6 Reserve vessel low level alarm works correctly? Set Point:

4.7 Local alarm light panel (if installed) functions properly?

4.8 Emergency oxygen supply connection (EOSC)

installed? (N/A for stand-alone hyperbarics facility.)

4.9 Cylinder Reserve: In acceptable condition, with legible

product label and lot number, and properly secured?

4.10 Cylinder Reserve: Pressure is acceptable (not

depleted)? Consider replacing if ~1900 psig. Pressure:

4.11 System will automatically switch to the reserve supply?

4.12 System verified to be free of unauthorized changes?

Bulk Installation Inspection Form - MED - Rev 02-28-20 Page 4

5 NITROUS OXIDE AND CARBON DIOXIDE YES NO N/A NOTES/COMMENTS

5.1 Each fill connection has blow down valve at the CGA

connection and hose restraint cable in good condition?

5.2 Electrical disconnects appear to be in good condition

and no visual signs of blown fuses, loose conduit?

5.3 Refrigeration unit and compressor verified for proper

operation and maintained per MFR recommendations?

MFR and Size:

Refrignt Type:

5.4 Vessel pressure is above 250 psig and within design

range on data label? Record pressure in notes. Pressure:

5.5 Pressure building system tested and is operating

correctly at system set point per data label?

5.6 N2O only: 240 V power plug with disconnect and

grounding source for N2O truck are in good condition?

6 NEW INSTALLATION CHECKLIST YES NO N/A NOTES/COMMENTS

6.1 All field piping is pressure and leak tested to 110% of

design pressure per ASME B31.3?

6.2 Vessel and equipment anchored per standard or

engineered pad drawings?

6.3 All piping, fittings, and equipment installed for O2

service are verified clean for oxygen service?

6.4 Installations with P&ID are installed per design, any

modifications approved, and as-built verified?

6.5 Vessel first-filled and system purged with intended

product?

6.6 Vessel and system set points meet design and

customer requirements?

6.7 Regulator strainers checked for debris and lines purged

if neccessary?

6.8 Site, Vessel, and Equipment requirements in checklist

sections above are in compliance?

COMMENTS:

Technician Name: Customer Name:

Technician Signature: Customer Signature: