S02 0001 Attch 1 2024 Seattle VA Medical Gas Inspection Report.pdf

2.0 Scope and Management Summary

• The scope of this report is a medical gas inspection to a category 1 facility as defined by NFPA-99, 2021 edition Chapter 4.

• Medical Gases, Support Gases, vacuum involved were oxygen, medical air, surgical vacuum, nitrous oxide and nitrogen.

The Medical Gas System inspection tests were performed as outlined in the JC EC.02.05.09 and the NFPA-99, 2021 edition.

1. Bulk/Manifold location, function, and alarm reporting

2. Pump/compressor location, performance, and alarm reporting

3. Master/area alarm location, function, and labeling

4. Valve performance, location, and labeling

5. Inlet/Outlet latch, flow, and concentration

3.0 Management Summary

The medical gas systems tested above are inspected to be in compliance with the NFPA99, 2021 edition.

Tests/Verification performed:

3.1 Oxygen bulk site

The site meets NFPA55 requirements except for any noted deficiencies.

1. Bulk tank is owned by the VA Medical System

2. Bulk site is inspected by: Praxair

3. Site maintenance and safeties are managed by: Praxair

4. Local and site master alarm signals are tested by:

3.2 Medical/Instrument Air compressors

The mechanical room meets NFPA99 requirements except for any noted deficiencies.

5. Primary to lag cycle works with lag in use alarm sent to master alarm panels.

6. Run timers work as designed.

7. Overall condition of medical/instrument air compressors is: Good

3.3 Vacuum pumps

The mechanical room meets NFPA99 requirements except for any noted deficiencies.

8. Primary to lag cycle works with Lag in use alarm sent to master alarm panels.

9. Run timers work as designed.

10. Overall condition of vacuum pumps is: Good http://www.medgas.com/

3.4 Medical gas manifolds – N2O & N2

The manifold room meets NFPA99 requirements except for any noted deficiencies.

11. Switch from left bank to right and right bank to left with local and master alarm reporting.

12. All redundancies and labeling are correct.

13. Vent lines brazed and labeled.

3.5 Master Alarm panels

The master alarm panels meet NFPA99 requirements except for any noted deficiencies.

14. Location

15. Each alarm is labeled correctly.

16. Individual alarm locations on each master alarm panel are identical.

17. Audible and visual functions tested.

3.6 Valves

The valves meet NFPA99 requirements except for any noted deficiencies.

18. Source/main valves are secure and properly labeled.

19. EOSC is properly labeled, secured, and staff is familiar with its use.

20. Zone valves are properly located and labeled.

3.7 Inlets and Outlets

The inlets and outlets in each patient care area were tested.

21. Latches function as designed.

22. Flow rates meet SCFM guidelines for the area served.

23. Concentration of gas meets NFPA99 standards – See below.

3.8 Medical Gas Concentration Testing (5.1.12.3.11)

The specific tasks performed to inspect the medical gas concentrations are analyzed to meet or exceed the following table: (Table 5.1.12.3.11 Gas Concentrations)

Oxygen ≥99% oxygen Nitrous Oxide ≥99% nitrous oxide Nitrogen ≤1% oxygen Medical air 19.5%-23.5% oxygen Other gases ±1%, unless otherwise specified

4.0 Quality Control

The Quality control program is designed to assure that measurements made in this report are correct and accurate. To this end, the following equipment was used in testing.

Function Make Model Serial # Calibration frequency

Calibration due

Oxygen MaxTec FJ73599008 Daily N/A Flow Dwyer X100 N/A 12 months 4/06/2025

Pressure Dwyer DPG-107 1P18322C16AB-8 12 months 4/06/2025 Purity Enmet Matrix + 125-01256 12 months 2/20/2025

Scale 1/10,000g Sartorius FJ73599008 Daily N/A

5.0 Personnel

The following personnel completed the annual medical gas inspection

Name Title Credentials Expiration date Covid vaccination Lead ASSE 6040 3/2027 YES Ashton Steely Apprentice YES

6.0 Outlets/Inlets tested

The following is the outlet and inlet tested/not tested counts

Oxygen Medical Air

Vacuum Nitrous Oxide

WAGD Nitrogen

Tested 630 474 609 16 2 22 Not Tested* 10 8 16 0 0 0 Total 640 482 625 16 2 22

*Not tested is an estimated count of outlets and inlets

MEDICAL GAS & VACUUM REPORT KEY

FACILITY CONTACT: Ken Albright Kenneth.albright@avaloncontracting.com 253-964-2487 ADDRESS: 1660 S. Columbian Way Seattle, WA 98108 Services certifies that all items listed within report have been inspected and, were in compliance with NFPA 99C, The Joint Commission EC. 02.05.09, AIA and CGA guidelines on the date tested, except for those items so indicated in this test report.

ITEMS INSPECTED SYSTEM COLOR CODE

PATIENT TERMINALS &

FLEXIBLE CONNECTORS O, A, V, NO, N O = OXYGEN

SOURCE EQUIPMENT O, A, V, NO, N A = MEDICAL AIR

MEDICAL ISOLATION VALVES O, A, V, NO, N V = VACUUM

MASTER ALARMS O, A, V, NO, N NO = NITROUS OXIDE

AREA ALARMS O, A, V, NO, N C = CARBON DIOXIDE

CROSS CONNECTIONS O, A, V, NO, N N = NITROGEN

CONCENTRATION O, A, NO W = WASTE ANESTHESIA GAS

PURITY & PARTICULATE * NOT IN SCOPE OF ANNUAL

INSPECTIONS I = INSTRUMENT AIR

The medical gas systems that are represented in this report have been evaluated in accordance with NFPA99 by personnel who are familiar and credentialed to perform the duties outlined in the ASSE 6000 and NFPA99 2021 edition.

The systems have been found to meet or exceed the requirements of the NFPA99 except where noted in the final inspection report.

IF YOUR FACILITY, OR CERTAIN AREAS OF YOUR FACILITY, IS NOT IN STRICT COMPLIANCE WITH THE NFPA99, THE AUTHORITY HAVING JURISDICTION SHOULD DECIDE WHETHER TO CORRECT THE DEFICIENCIES, UPGRADE THE

AREA TO MEET THE NFPA99 2018, OR REMAIN THE SAME.

mailto:Kenneth.albright@avaloncontracting.com

SUMMARY REPORT

OBSERVATIONS FOR UPGRADES – NOT A RECOMMENDATION

Location Problem/Deficiency Suggestion Reference Corrected by & date

BULK PAD O2 MAIN LINE HI/LO PRESSURE SWITCH IS

UPSTREAM OF THE MAIN VALVE.

MOVE PRESSURE SWITCH DOWN STREAM OF MAIN

VALVE

5.1.9.2.5

BULK PAD EOSC IS LOCATED ON SAME PAD AS BULK TANK. MOVE EOSC TO EXTERIOR OF THE BUILDING 5.1.3.5.13.1(1) BULK PAD ADD LOCK TO SECURE EOSC. ADD LOCK TO EOSC TO PREVENT TAMPERING 5.1.3.5.13.2(1)

ENERGY PLANT

MECHANICAL ROOM

MEDICAL AIR INTAKE IS NOT HARD DRAWN COPPER

(PVC)

REPLACE INTAKE WITH HARD DRAWN COPPER PIPING 5.1.3.6.3.12(F),

5.1.10.1.4(1)

BUILDING 101

BASEMENT HALLWAY

DEW POINT HIGH ALARM IS NOT MONITORED AT THE

MASTER ALARM PANELS

INSTALL WIRES FOR ALARM [5.1.9.2]

ENERGY PLANT

MECHANICAL ROOM

CO HIGH ALARM IS NOT MONITORED AT THE

MASTER ALARM PANELS

WIRE CO HIGH ALARM TO MASTER ALARM PANELS 5.1.3.6.3.13(3)

ENERGY PLANT

MECHANICAL ROOM

DEW POINT HIGH ALARM IS NOT MONITORED AT THE

MASTER ALARM PANELS

WIRE DEW POINT HIGH ALARM TO MASTER ALARM

PANELS

5.1.3.6.3.13(3)

ENERGY PLANT

MECHANICAL ROOM

LABELING IS INCORRECT COLOR CODING REPLACE LABEL WITH CORRECT COLOR CODING TABLE 5.1.11

ENERGY PLANT

MECHANICAL ROOM

VACUUM PRESSURE SWITCH PIPED TO WRONG SIDE

OF SOURCE VALVE.

MOVE SWITCH TO OTHER SIDE OF SOURCE VALVE 5.1.9.2.5

MANIFOLD ROOM NITROGEN DOES NOT HAVE RELIEF VENT PIPING ADD RELIEF VENT PIPING 5.1.3.5.6.1(4) MANIFOLD ROOM VENT LINE DISCHARGES IN AN UNKNOWN LOCATION MOVE VENT DISCHARGE LOCATION 5.1.3.5.6.1(7)

MANIFOLD ROOM N2 AND N20 MAIN LINE PRESSURE SWITCH IS

LOCATED UPSTREAM OF MAIN VALVE

MOVE MAINLINE PRESSURE SWITCH TO OTHER SIDE

OF MAIN VALVE

5.1.8.2.2 (1)

MANIFOLD ROOM CANNOT DETERMINE IF VENT LINE IS SCREENED. LOCATED AND DETERMINE IF VENT LINE IS SCREENED

AND TURNED DOWN

5.1.3.5.6.1 (8)

MANIFOLD ROOM MANIFOLD VENTS INTO BOTTLE ROOM ADD VENT TO DRAW GASSES OUT OF MANIFOLD

ROOM

5.1.3.5.6.1 (4)

MANIFOLD ROOM MAIN LINE PRESSURE SWITCH IS LOCATED UPSTREAM

OF MAIN VALVE

MOVE PRESSURE SWITCH TO OTHER SIDE OF MAIN

VALVE

5.1.9.2.5

BLDG 100 1ST FL SCI

106,130,138- 139,142

NO VAC ZONE VALVE AND NO GAUGES ADD VACUUM ZVB, ADD OXYGEN AND MEDICAL AIR

GAUGES

5.1.4.6.3 /5.1.4.6.4

BLDG 100 1ST FL SCI NO GAUGES DOWNSTREAM OF ZONE VALVES FOR

ROOMS 107, 110, 112, 115, 117, 119, 123, 124,

126, 127, & 129

ADD OXYGEN, MEDICAL AIR, AND VAC GAUGES

DOWN STREAM OF ZVB

5.1.4.6.4

BLDG 100 1ST FL SCI AREA ALARM PANEL IS OUT OF RANGE AND IS

OBSOLETE FOR ROOMS 107, 110, 112, 115, 117,

119, 123, 124, 126, 127, & 129

REPLACE AREA ALARM PANEL 5.1.9.4.6

BLDG 100 1ST FL SCI

EAST

NO GAUGES DOWNSTREAM OF ZONE VALVES ADD OXYGEN, MEDICAL AIR, AND VAC GAUGES

DOWN STREAM OF ZVB

5.1.4.6.4

BLDG 100 1ST FL SCI

EAST

AREA ALARM PANEL IS OUT OF RANGE AND IS

OBSOLETE

REPLACE AREA ALARM PANEL 5.1.9.4.6

BLDG 100 2ND FL 2

EAST

NO VACUUM ZONE VALVE, OTHER VALVES MISSING

GAUGES

ADD VACUUM ZONE VALVE BOX 5.1.4.6.3

BLDG 100 2ND FL 2

EAST

OXYGEN VALVE LEAKS WHEN CLOSED REPLACE ZONE VALVE BOX 5.1.4.6.4

BLDG 100 2ND FL 2

EAST

ROOM ARE MISLABELED. PROPERLY LABEL ROOMS

BLDG 100 2ND FL 2

EAST

VACUUM ALARM DOES NOT WORK REPLACE AREA ALARM 5.1.12.4.5.3

BLDG 100 2ND FL 2

EAST

ROOM 111 OUTLETS BLOCKED BY CABINET MOVE CABINETS OR BLANK OFF OUTLETS OBSERVATION

LOCATION PROBLEM/DEFICIENCY SUGGESTION REFERENCE CORRECTED BY &

DATE

BLDG 100

2ND FL MRI

MISSING VAC ALARM REPLACE OBSOLETE AREA ALARM PANEL 5.1.9.4.6

BLDG 100

2ND FL MRI

ALARM PANEL IS OUTDATED REPLACE ALARM PANEL

BLDG 100

2ND FL

DENTAL

NO GAUGES ON ZONE VALVES ADD ZVB GAUGES 5.1.4.6.4

BLDG 100

3RD FL 3

EAST

VACUUM IS MISSING FROM ZVB, NO GAUGES

FOR OXYGEN OR MEDICAL AIR. MEDICAL AIR

VALVE IS MISSING NUT

REPLACE ZVB 5.1.4.6.3

BLDG 100

3RD FL 3

EAST

ROOM 3C 133 MIDDLE VACUUM INLET

LEAKS

REPAIR OR REPLACE INLET

BLDG 100

3RD FL 3

WEST

NO VACUUM ZONE VALVE, OTHER VALVES

MISSING GAUGES.

ADD VACUUM ZVB, ADD OXYGEN AND MEDICAL AIR GAUGES 5.1.4.6.3 /5.1.4.6.4

BLDG 100

3RD FL PACU

NO VACUUM ZONE VALVE, OTHER VALVES

MISSING GAUGES. SHARED ZVB BUT

SEPARATE ALARMS

ADD VACUUM ZVB, ADD OXYGEN AND MEDICAL AIR GAUGES 5.1.4.6.3 /5.1.4.6.4

BLDG 100

3RD FL OR1-

OR5, OR7, &

OR HOLDING

MISSING GAUGES DOWNSTREAM OF ZONE

VALVES

ADD ZVB GAUGES 5.1.4.6.4

BLDG 100

3RD FL OR1-

OR8

AREA ALARM IS OUT OF RANGE AND

OBSOLETE

REPLACEMENT OF AREA ALARM PANEL IS IN PROGRESS

BLDG 100

3RD FL OR5

MED AIR LABEL IN ZONE VALVE BOX IS

WRONG COLOR

PUT RIGHT COLORED LABEL ON ZONE VALVE FOR MED AIR TABLE 5.1.11

Bldg 100 3rd

FL OR 5

OXYGEN ZONE VALVE LEAKS Repair or Replace zone valve

Bldg 100 3rd

FL OR8

CAN NOT SEE THE GAUGES THRU THE ZVB

COVER.

Add correct zvb cover to see zvb gauges

Bldg 100 4th FL 4 West serving: 4B 119, 121, 123-126, 128, 132

NO GAUGES DOWN STREAM OF ZONE

VALVES. MISSING VACUUM ZONE VALVE.

Add vacuum zvb, add gauges downstream of zvb for oxygen and medical air

5.1.4.6.4

Bldg 100 4th FL 4 West serving: 4B 137-140, 144-146, 148, 149, NO GAUGES DOWN STREAM OF ZONE

VALVES. MISSING VACUUM ZONE VALVE.

Add vacuum zvb, add gauges downstream of zvb for oxygen and medical air

5.1.4.6.4

Bldg 100 4th 4 West

ROOM 4B 149 LEFT O2 LEAKS WITH DEVICE Repair or replace outlet

Bldg 100 4th FL Cath

ZVB LOCATED BEHIND A DOOR, WHEN DOOR

OPENS

Relocate zone valve box

Bldg 100 4th FL Cath

MED AIR AND VAC DIGITAL DISPLAYS BY

FLASHING NUMBER

Replace obsolete area alarm panel

Bldg 100 4th FL Bone Marrow

NO GAUGES DOWN STREAM OF VALVES. O2

LEAKS WHILE CLOSING

Add zvb gauges down stream, replace oxygen zone valve

5.1.4.6.4

Bldg 100 4th FL Bone Marrow

AREA ALARM PANEL OBSOLETE. MA DOES

NOT ALARM WHEN PRESSURE IS LOW.

Replace obsolete area alarm panel

Bldg 100 4th FL Bone Marrow

ROOM 7 MED AIR LEAKS WITHOUT DEVICE Repair or replace outlet

Bldg 100 5th FL 5 East

ZONE VALVES DO NOT HAVE GAUGES.

CANNOT SEE PIPE SIZES. O2 LEAKS WHEN

CLOSING

Replace zone valve box

Bldg 100 5th FL 5 East

ROOM 5C-135 MED AIR LEAKS Repair or Replace outlet

Bldg 100 5th FL 5 West

ZONE VALVES DO NOT HAVE GAUGES,

CANNOT SEE PIPE SIZES

Add gauges to zvb 5.1.4.6.4

Bldg 100 5th FL 5 West

STATION 8 OXYGEN LEAKS Repair or replace outlet

Bldg 100 6th FL 6 East

ZONE VALVE BOX IS LOCATED BEHIND DOOR Move zone valve box or remove door. 5.1.4.6.1(4)

Bldg 100 6th FL 6 West

ZONE VALVES DO NOT HAVE GAUGES. O2

LEAKS WHEN OPERATED.

Add gauges to zone valves, Repair O2 outlet 5.1.4.6.4

Bldg 100 7th FL 7 East

ZONE VALVES DO NOT HAVE GAUGES Add gauges to zone valves 5.1.4.6.4

Bldg 100 7th FL 7 East

O2 VALVE LEAKS WHEN OPERATED Repair or replace valve

LOCATION OF COMPRESSOR: BUILDING 101 BASEMENT HALLWAY AREA SERVED: FACILITY BUILDING 101

UNIT MANUFACTURER: EMSE TECH SUPPORT PHONE: 1-800-962-5385

UNIT MODEL NUMBER: 3DOHS10PS240D SERIAL NUMBER: 3953B1607

COMPRESSOR MANUFACTURER: EMSE HP: 10 VOLTAGE: 460

COMPRESSOR DATA MODEL # SERIAL # 2023 HOURS 2024 HOURS

UNIT 1 SRL75CBO QB003871 0 0

UNIT 2 SRL75CBO QB003684 0 0

UNIT 3

UNIT 4

THE MEDICAL AIR MAIN LINE PRESSURE IS: 52 PSI GAUGE RANGE IS: 0-160 PSI

THE LEAD COMPRESSOR IS ON AT 90 PSI AND OFF AT 100 PSI LAG IS ON AT 85 PSI AND OFF AT 90 PSI

DEW POINT READING -92 ⁰F @ 52 PSI

DP MANUFACTURER: KAHN DP MODEL # 75-400P1582 SERIAL # BD45-065 0516

CARBON MONOXIDE READING: 0PPM

CO MANUFACTURER: GFG CO MODEL # 4021 SERIAL # 160415638

DRYER MANUFACTURER: PURE GAS DRYER MODEL # HR6.5-11 SERIAL # 0716-92835

MEDICAL AIR ANALYSIS: ENMET MATRIX ANALYZER S/N 125-0256

DEW POINT: ⁰F OXYGEN PERCENTAGE: %

HYDROCARBONS (METHANE): PPM PASS CARBON MONOXIDE: PPM PASS

HYDROCARBONS (CHLOROFORM): PPM PASS CARBON DIOXIDE: PPM

TEMPERATURE AMBIENT @ COMPRESSOR INLET @ HEAT EXCHANGER

UNIT 1 65°F 111°F 195°F

UNIT 2 65°F 73°F 70°F

UNIT 3

UNIT 4

TIME: CUT IN/90PSI UNIT 1: 162SECONDS UNIT 2: 151 SECONDS UNIT 3: UNIT 4:

Yes No N/A ☒ ☐ ☐ 1. Is the room adequately vented to prevent accumulation of heat per manufacturers’ specifications? [5.1.3.3.3.2 (1)] ☒ ☐ ☐ 2. Does each compressor have a check valve to prevent backflow through off-cycle units?

[5.1.3.6.3.2 (2)] ☒ ☐ ☐ 3. Do the compressors have sufficient isolation valves on the patient side of the compressors? [5.1.3.6.3.2 (3)] ☒ ☐ ☐ 4. Do the compressors have sufficient anti-vibration mountings? [5.1.3.6.3.4 (E)]

☒ ☐ ☐ 5. Do the compressors have sufficient flex connections for intake and outlet piping?

[5.1.3.6.3.4 (F)]

☒ ☐ ☐ 6. Is there a dry type intake filter? [5.1.3.6.3.2 (4)]

7. Medical Air Intake location: Roof, above mechanical room Yes No ☒ ☐ a) Is the medical air intake source free of contaminants from odor, exhaust, fuel, vacuum discharge, or particulate? [5.1.3.6.3.12] ☒ ☐ b) Are outdoor intakes located above roof level and at least 10 ft. from any door, window, or other opening and 20’ from other intake and exhaust and a minimum of 20 ft. above ground? [5.1.3.6.3.12 (C-D)]

☒ ☐ c) Is intake piping hard drawn copper? [5.1.3.6.3.12 (F)] ☒ ☐ d) Do the compressors have a means to isolate common intake piping when a compressor is removed for service? NOTE: If the answer is No, a tube cap can be used when compressors are removed from service.

4[5.1.3.6.3.12 (G-2)]

Yes No N/A

☒ ☐ ☐ 8. Is the system capable of automatically activating additional units to maintain pressure?

[5.1.3.6.3.11 (A)]

Yes No ☒ ☐ a) Is there a Lag Compressor local alarm with audible and visual signals when the last compressor starts? [5.1.9.5.4 (1)] ☒ ☐ b) Does the signal latch, requiring manual reset? [5.1.3.6.3.13 (E)] ☒ ☐ c) Is it wired to master alarm? [5.1.9.2]

☒ ☐ ☐ 9. Do controls provide for automatic alternation of units? [5.1.3.6.3.11 (B)] Yes No ☒ ☐ a) Are motor controls equipped with disconnect switch, motor starting device and overload protection? [5.1.3.6.3.11 (C)] ☒ ☐ b) Are the compressors powered by the equipment branch of the essential electrical system? [5.1.3.6.3.11 (E)] ☒ ☐ ☐ 10. Is there a Receiver?

Yes No ☒ ☐ a) Is the receiver equipped with corrosion resistant material, ASME label, relief valve, automatic drain, manual drain sight glass and three-valve bypass? [5.1.3.6.3.6 (1-4)]

☒ ☐ b) Is the receiver equipped with pressure gauge? [5.1.3.6.3.6 (3)]

☒ ☐ ☐ 11. Are there proper filtration devices which are duplexed with isolating valves?

[5.1.3.6.3.8]

Yes No ☒ ☐ a) Are filters rated for 98% efficiency at 1 micron? [5.1.3.6.3.8 (3)] ☒ ☐ b) Do filters have a visual indicator showing status of the filter element?

[5.1.3.6.3.8 (4)]

Yes No N/A ☒ ☐ ☐ 12. Are there duplexed final line pressure regulators with isolating valves?

☒ ☐ ☐ 13. Is there a 75psi relief valve located on the patient side of the regulator? [5.1.3.6.3.2 (5)]

☒ ☐ ☐ 14. Is there a working dew point monitor installed in the Medical Air System?

Yes No Yes No ☒ ☐ Is there a visual and audible local alarm? ☐ ☒ Is it wired to the master alarms?

☒ ☐ ☐ 15. Is there a working carbon monoxide monitor installed in the Medical Air System?

Yes No Yes No ☒ ☐ Is there a visual and audible local alarm? ☐ ☒ Is it wired to the master alarm?

☒ ☐ ☐ 16. Do the dew point and CO monitors activate their respective master alarm signals with the loss of power?

☒ ☐ ☐ 17. Is there a valve-controlled sample port?

Yes No ☒ ☐ a) Is the sample port located between the monitors for dewpoint and CO and the source valve?

☒ ☐ ☐ 18. Is the source valve installed in the immediate vicinity of the source equipment?

Yes No ☒ ☐ Is it labeled?

☒ ☐ a) Is the source valve located inside the building served? If not, a main valve is required.

☒ ☐ b) Is the valve a three-piece ball valve with indicating handle and brazing extensions?

☒ ☐ ☐ 19. Is there a high/low line pressure master alarm pressure switch?

Yes No ☒ ☐ a) Is the switch located downstream of the source and main line valve (if the same)?

☒ ☐ b) Is the switch connected with a demand check fitting?

☒ ☐ c) Is the demand check fitting gas specific?

☒ ☐ d) Is there a gauge installed next to the switch?

☒ ☐ ☐ 20. Is the source piping appropriately labeled for gas served with standard colors?

☒ ☐ ☐ 21. Does all source piping consist of copper, brass, or stainless steel? (Compressors can have ferrous materials.)

☒ ☐ ☐ 22. Are all copper joints brazed or Lokring?

☒ ☐ ☐ 23. Is there a preventative maintenance program established for the Medical Air equipment?

☒ ☐ ☐ 24. Are there high head temperature alarm sensors installed?

Yes No ☒ ☐ a) Is there a visual and audible local alarm?

☒ ☐ b) Is it wired to master alarm?

COMMENTS:

14. DEW POINT NOT WIRED TO MASTER ALARM.

15. CO MONITOR NOT WIRED TO MASTER ALARM.

LOCATION OF VACUUM PUMP: BASEMENT OF BUILDING 101, LOADING

DOCK HALLWAY

AREA SERVED: FACILITY BUILDING 101

UNIT MANUFACTURER: EMSE TECH SUPPORT PHONE: 1 800-935-3673

UNIT MODEL NUMBER: 1DOB5HS120 SERIAL NUMBER: 3953D1607

PUMP MANUFACTURER: BECKER HP: 5 VOLTAGE: 460

VACUUM PUMP DATA MODEL # SERIAL # 2023 HOURS 2024 HOURS

UNIT 1 KVT 3.100/.0-54 D3011264 11 23

UNIT 2 KVT 3.100/.0-54 D3011265 11 22

UNIT 3

UNIT 4

THE VACUUM MAIN LINE PRESSURE IS: 22”HG GAUGE RANGE IS: 0-30HG

THE LEAD PUMP IS ON AT 19 ” HG AND OFF AT 22” HG LAG IS ON AT 16 ” HG AND OFF AT 19” HG

TEMPERATURES AMBIENT OIL SITE GLASS HEAT EXCHANGER/OIL FILTER PUMP EXHAUST

UNIT 1 67 °F N/A N/A 69 °F

UNIT 2 67°F N/A N/A 69°F

UNIT 3

UNIT 4

TIME CUT IN/22”HG 29 SECONDS 30 SECONDS

Yes No N/A ☒ ☐ ☐ 1. Is the data on this sheet for the following source(s): LEAD & LAG?

☒ ☐ ☐ 2. Is the entire area Facility served by this source?

☒ ☐ ☐ 3. Is the room adequately vented to prevent accumulation of heat per manufacturers’ recommendation?

☒ ☐ ☐ 4. Are there two or more pumps?

☒ ☐ ☐ 5. Does each pump have a check valve to prevent backflow through off-cycle units?

☒ ☐ ☐ 6. Does each pump have isolation valves on intake piping?

☒ ☐ ☐ 7. Does each pump have isolation valves (or equivalent) on exhaust piping? NOTE: If the answer is no, a tube cap can be used when pumps are removed from service.

☒ ☐ ☐ 8. Is there sufficient flexible couplings installed in the piping to and from the equipment?

☒ ☐ ☐ 9. Is there a receiver?

Yes No ☒ ☐ a) Does the receiver have an ASME data plate?

☒ ☐ b) Does the receiver have sufficient manual drain?

☒ ☐ c) Is the receiver valved to allow draining or servicing without interrupting the Vacuum system?

☒ ☐ ☐ 10. Is system capable of automatically activating additional units to maintain vacuum?

Yes No ☒ ☐ a) Is there a local audible / visual signal when lag pump is in operation?

☒ ☐ b) Does the signal latch, requiring manual reset?

☒ ☐ c) Is it wired to master alarm panels?

☒ ☐ ☐ 11. Is there automatic pump alternation to provide for even wear?

☒ ☐ ☐ 12. Are there dedicated disconnect switches, motor starting devices, and overload protection for each pump?

☒ ☐ ☐ 13. Is power supplied by the equipment branch of the essential electrical system?

14. Vacuum Exhaust:

Yes No ☒ ☐ a) Is the exhaust outdoors and at least 10 ft. from any door, window, air intake, or other opening in the building?

☒ ☐ b) Is the exhaust discharge turned down and screened or otherwise protected from vermin, debris, or precipitation?

☒ ☐ c) Is there a trapped drip leg with valved drain on the exhaust line to discharge condensate or oil?

☒ ☐ d) Is the exhaust piping considered to be of proper size to minimize back pressure?

Exhaust Location: Above mechanical room

☒ ☐ ☐ 15. Is Vacuum distribution piping hard-drawn copper or stainless steel pipe?

☒ ☐ ☐ 16. Is the source piping appropriately labeled for Vacuum?

Yes No ☒ ☐ Is the label background color white?

☒ ☐ ☐ 17. Is the source valve in the immediate vicinity of the source equipment?

Yes No ☒ ☐ Is the source valve labeled?

☒ ☐ ☐ 18. Is there a line vacuum low switch wired to the master alarm panels?

Yes No ☒ ☐ a) Is the switch located on the patient side of the main valve, or source valve if there is no main valve?

☒ ☐ b) Is the switch connected with a demand check fitting?

☒ ☐ c) Is the demand check fitting gas specific?

☒ ☐ d) Is there a gauge installed next to the switch after source/mainline shutoff valve?

Location of switch: Just downstream of Main Valve

COMMENTS:

Location of bulk pad: Facilities loading dock Area Served: Facility Bulk supplier is: Praxair Emergency phone number: 800-772-9247 Main line pressure: 50 psi

* Leased Bulk Equipment is inspected annually by the equipment owners. does not make any adjustments to equipment or activate/test any master alarms initiated from the bulk pad.

Yes No N/A ☒ ☐ ☐ 1. Is there a high/low line pressure master alarm pressure switch? [5.1.9.2.4 (7)]

Yes No ☒ ☐ a) Is it wired to two master alarm panels? [5.1.9.2.1] ☐ ☒ b) Is the switch located on the patient side of the main valve, or source valve if there is no main valve? [5.1.8.2.3] ☒ ☐ c) Is the switch connected with a demand check fitting? [5.1.8.2.3] ☒ ☐ d) Is the demand check fitting gas specific? [5.1.8.2.3] ☒ ☐ e) Is there a gauge installed next to the switch after the source/mainline shutoff valve? [5.1.8.2.2 (1)]

☒ ☐ ☐ 2. Is an emergency oxygen supply connection (EOSC) present? [5.1.3.5.13.1] Yes No ☐ ☒ a) Is it located on the exterior of the building where it is accessible to emergency supply vehicles in all weather conditions? [5.1.3.5.13.(1)]

b) Is it physically protected to prevent tampering and unauthorized access?

[5.1.3.5.13.2 (1)]

c) Does the check valve function properly?

☒ ☐ ☐ 3. Is the source piping appropriately labeled for gas served with standard designation colors? [5.1.11.1.1 (1-3)]

☒ ☐ ☐ 4. Is the source valve installed in the immediate vicinity of the source equipment? [5.1.4.4]

Yes No ☒ ☐ a) Is the valve a three-piece ball valve with indicating handle and brazing extensions? [5.1.4.3 (1-5)]

☒ ☐ ☐ 5. Does a mainline shutoff valve exist where the main first enters the building if oxygen supply is remote? [5.1.4.5] Yes No ☒ ☐ a) Is it labeled? [5.1.4.5.3] ☒ ☐ b) Is the valve a three-piece ball valve with indicating handle and brazing extensions? [5.1.4.3 (1-5)]

☒ ☐ ☐ 6. Is the source equipment and EOSC free of leaks?

COMMENTS:

1B. MAIN LINE HI/LO PRESSURE SWITCH IS UPSTREAM OF THE MAIN VALVE.

2A. EOSC IS LOCATED ON SAME PAD AS BULK TANK.

2B. ADD LOCK TO SECURE EOSC.

Seattle VA Medical Center

Medical Air Compressor

SOURCE EVALUATION

LOCATION OF COMPRESSOR: ENERGY PLANT MECHANICAL ROOM AREA SERVED: FACILITY EXCEPT BLDG 101

UNIT MANUFACTURER: KOBELCO TECH SUPPORT PHONE: 713-655-8450

UNIT MODEL NUMBER: N/A SERIAL NUMBER:

COMPRESSOR MANUFACTURER: KOBELCO HP: 50/40 VOLTAGE: 460

COMPRESSOR DATA MODEL # SERIAL # 2021 HOURS 2023 HOURS

UNIT 1 KNWAO-B/L 12H6114153 51,839

UNIT 2 KNWAO0-DL 22K6121697 7,392

UNIT 3

UNIT 4

THE MEDICAL AIR MAIN LINE PRESSURE IS: 50 PSI GAUGE RANGE IS: 0-100

THE LEAD COMPRESSOR IS ON AT 90 PSI AND OFF AT 120 PSI LAG IS ON AT 80 PSI AND OFF AT 110 PSI

DEW POINT READING -87⁰F @ 50 PSI

DP MANUFACTURER: ENMET DP MODEL # MEDAIR 2200 SERIAL # 100-1109

CARBON MONOXIDE READING: 0 PPM

CO MANUFACTURER: ENMET CO MODEL # MEDAIR 2200 SERIAL # 100-1109

DRYER MANUFACTURER: BEACON MEDAES DRYER MODEL # 4107007851 SERIAL # HOP550277

MEDICAL AIR ANALYSIS: ENMET MATRIX ANALYZER S/N 125-0256

DEW POINT: -88⁰F OXYGEN PERCENTAGE: 21.2%

HYDROCARBONS (METHANE): 1 PPM PASS CARBON MONOXIDE: 1 PPM PASS

HYDROCARBONS (CHLOROFORM): 0.0 PPM PASS CARBON DIOXIDE: 30 PPM

TEMPERATURE AMBIENT @ COMPRESSOR INLET @ HEAT EXCHANGER

UNIT 1 74°F 72°F 80°F

UNIT 2 74°F 73°F 83°F

UNIT 3

UNIT 4

TIME: CUT IN/90PSI UNIT 1: VS UNIT 2:VS UNIT 3: UNIT 4:

Yes No N/A ☒ ☐ ☐ 1. Is the room adequately vented to prevent accumulation of heat per manufacturers’ specifications? [5.1.3.3.3.2 (1)] ☒ ☐ ☐ 2. Does each compressor have a check valve to prevent backflow through off-cycle units?

[5.1.3.6.3.2 (2)] ☒ ☐ ☐ 3. Do the compressors have sufficient isolation valves on the patient side of the compressors? [5.1.3.6.3.2 (3)] ☒ ☐ ☐ 4. Do the compressors have sufficient anti-vibration mountings? [5.1.3.6.3.4 (E)]

☒ ☐ ☐ 5. Do the compressors have sufficient flex connections for intake and outlet piping?

[5.1.3.6.3.4 (F)]

☒ ☐ ☐ 6. Is there a dry type intake filter? [5.1.3.6.3.2 (4)]

7. Medical Air Intake location: Roof, above mechanical room Yes No ☒ ☐ a) Is the medical air intake source free of contaminants from odor, exhaust, fuel, vacuum discharge, or particulate? [5.1.3.6.3.12] ☒ ☐ b) Are outdoor intakes located above roof level and at least 10 ft. from any door, window, or other opening and 20’ from other intake and exhaust and a minimum of 20 ft. above ground? [5.1.3.6.3.12 (C-D)]

☐ ☒ c) Is intake piping hard drawn copper? [5.1.3.6.3.12 (F)] ☒ ☐ d) Do the compressors have a means to isolate common intake piping when a compressor is removed for service? NOTE: If the answer is No, a tube cap can be used when compressors are removed from service.

4[5.1.3.6.3.12 (G-2)]

Yes No N/A

☒ ☐ ☐ 8. Is the system capable of automatically activating additional units to maintain pressure?

[5.1.3.6.3.11 (A)]

Yes No ☒ ☐ a) Is there a Lag Compressor local alarm with audible and visual signals when the last compressor starts? [5.1.9.5.4 (1)] ☒ ☐ b) Does the signal latch, requiring manual reset? [5.1.3.6.3.13 (E)] ☒ ☐ c) Is it wired to master alarm? [5.1.9.2]

☒ ☐ ☐ 9. Do controls provide for automatic alternation of units? [5.1.3.6.3.11 (B)] Yes No ☒ ☐ a) Are motor controls equipped with disconnect switch, motor starting device and overload protection? [5.1.3.6.3.11 (C)] ☒ ☐ b) Are the compressors powered by the equipment branch of the essential electrical system? [5.1.3.6.3.11 (E)] ☒ ☐ ☐ 10. Is there a Receiver?

Yes No ☒ ☐ a) Is the receiver equipped with corrosion resistant material, ASME label, relief valve, automatic drain, manual drain sight glass and three-valve bypass? [5.1.3.6.3.6 (1-4)]

☒ ☐ b) Is the receiver equipped with pressure gauge? [5.1.3.6.3.6 (3)]

☒ ☐ ☐ 11. Are there proper filtration devices which are duplexed with isolating valves?

[5.1.3.6.3.8]

Yes No ☒ ☐ a) Are filters rated for 98% efficiency at 1 micron? [5.1.3.6.3.8 (3)] ☒ ☐ b) Do filters have a visual indicator showing status of the filter element?

[5.1.3.6.3.8 (4)]

☒ ☐ ☐ 12. Are there duplexed final line pressure regulators with isolating valves?

☒ ☐ ☐ 13. Is there a 75psi relief valve located on the patient side of the regulator? [5.1.3.6.3.2 (5)]

☒ ☐ ☐ 14. Is there a working dew point monitor installed in the Medical Air System?

Yes No Yes No ☒ ☐ Is there a visual and audible local alarm? ☐ ☒ Is it wired to the master alarms?

☒ ☐ ☐ 15. Is there a working carbon monoxide monitor installed in the Medical Air System?

Yes No Yes No ☒ ☐ Is there a visual and audible local alarm? ☐ ☒ Is it wired to the master alarm?

☐ ☒ ☐ 16. Do the dew point and CO monitors activate their respective master alarm signals with the loss of power?

☒ ☐ ☐ 17. Is there a valve-controlled sample port?

Yes No ☒ ☐ a) Is the sample port located between the monitors for dewpoint and CO and the source valve?

☒ ☐ ☐ 18. Is the source valve installed in the immediate vicinity of the source equipment?

Yes No ☒ ☐ Is it labeled?

☒ ☐ a) Is the source valve located inside the building served? If not, a main valve is required.

☒ ☐ b) Is the valve a three-piece ball valve with indicating handle and brazing extensions?

☒ ☐ ☐ 19. Is there a high/low line pressure master alarm pressure switch?

Yes No ☒ ☐ a) Is the switch located downstream of the source and main line valve (if the same)?

☒ ☐ b) Is the switch connected with a demand check fitting?

☒ ☐ c) Is the demand check fitting gas specific?

☒ ☐ d) Is there a gauge installed next to the switch?

☒ ☐ ☐ 20. Is the source piping appropriately labeled for gas served with standard colors?

☒ ☐ ☐ 21. Does all source piping consist of copper, brass, or stainless steel? (Compressors can have ferrous materials.)

☒ ☐ ☐ 22. Are all copper joints brazed or Lokring?

☒ ☐ ☐ 23. Is there a preventative maintenance program established for Medical Air equipment?

☒ ☐ ☐ 24. Are there high head temperature alarm sensors installed?

Yes No ☒ ☐ a) Is there a visual and audible local alarm?

☐ ☒ b) Is it wired to master alarm? (Not required)

COMMENTS:

7C. MEDICAL AIR INTAKE IS NOT HARD DRAWN COPPER (PVC)

INTAKE FILTER NEEDS REPLACED. 14-1/2” ROUND X 14-1/2” TAL

14. DEW POINT HIGH ALARM IS NOT MONITORED AT THE MASTER ALARM PANELS

15. CO HIGH ALARM IS NOT MONITORED AT THE MASTER ALARM PANELS

Surgical Vacuum

SOURCE EVALUATION DATA (RENTAL UNIT)

LOCATION OF VACUUM PUMP: ENERGY PLANT MECHANICAL ROOM AREA SERVED: FACILITY

UNIT MANUFACTURER: ROGERS MACHINE TECH SUPPORT PHONE: 503-639-6151

UNIT MODEL NUMBER: KRVP-20-VAC SERIAL NUMBER: 21B6525682

PUMP MANUFACTURER: KOBELCO HP: 20 VOLTAGE: 460

VACUUM PUMP DATA MODEL # SERIAL # 2023 HOURS 2024 HOURS

UNIT 1 KRVP-20-VAC 21B6525682 26,375

UNIT 2

UNIT 3

UNIT 4

THE VACUUM MAIN LINE PRESSURE IS: 22”HG GAUGE RANGE IS: 0-30HG

THE LEAD PUMP IS ON AT 18” HG AND OFF AT 24” HG LAG IS ON AT N/A AND OFF AT

TEMPERATURES AMBIENT OIL SITE GLASS HEAT EXCHANGER/OIL FILTER PUMP EXHAUST

UNIT 1 72°F N/A N/A°F 98°F

UNIT 2

UNIT 3

UNIT 4

TIME CUT IN/22”HG PUMP 1 N/A

Yes No N/A ☐ ☒ ☐ 1. Is the data on this sheet for the following source(s): LEAD & LAG?

☒ ☐ ☐ 2. Is the entire area Facility served by this source?

☒ ☐ ☐ 3. Is the room adequately vented to prevent accumulation of heat per manufacturers’ recommendation?

☐ ☒ ☐ 4. Are there two or more pumps?

☒ ☐ ☐ 5. Does each pump have a check valve to prevent backflow through off-cycle units?

☒ ☐ ☐ 6. Does each pump have isolation valves on intake piping?

☒ ☐ ☐ 7. Does each pump have isolation valves (or equivalent) on exhaust piping? NOTE: If the answer is no, a tube cap can be used when pumps are removed from service.

☒ ☐ ☐ 8. Is there sufficient flexible couplings installed in the piping to and from the equipment?

☒ ☐ ☐ 9. Is there a receiver?

Yes No ☒ ☐ a) Does the receiver have an ASME data plate?

☒ ☐ b) Does the receiver have sufficient manual drain?

☒ ☐ c) Is the receiver valved to allow draining or servicing without interrupting the Vacuum system?

☐ ☒ ☐ 10. Is system capable of automatically activating additional units to maintain vacuum?

Yes No ☐ ☒ a) Is there a local audible / visual signal when lag pump is in operation?

☐ ☒ b) Does the signal latch, requiring manual reset?

☐ ☒ c) Is it wired to master alarm panels?

☐ ☒ ☐ 11. Is there automatic pump alternation to provide for even wear?

☒ ☐ ☐ 12. Are there dedicated disconnect switches, motor starting devices, and overload protection for each pump?

☒ ☐ ☐ 13. Is power supplied by the equipment branch of the essential electrical system?

14. Vacuum Exhaust:

Yes No ☒ ☐ a) Is the exhaust outdoors and at least 10 ft. from any door, window, air intake, or other opening in the building?

☒ ☐ b) Is the exhaust discharge turned down and screened or otherwise protected from vermin, debris, or precipitation?

☒ ☐ c) Is there a trapped drip leg with valved drain on the exhaust line to discharge condensate or oil?

☒ ☐ d) Is the exhaust piping considered to be of proper size to minimize back pressure?

Exhaust Location: Above mechanical room

☒ ☐ ☐ 15. Is Vacuum distribution piping hard-drawn copper or stainless steel pipe?

☒ ☐ ☐ 16. Is the source piping appropriately labeled for Vacuum?

Yes No ☐ ☒ Is the label background color white?

☒ ☐ ☐ 17. Is the source valve in the immediate vicinity of the source equipment?

Yes No ☒ ☐ Is the source valve labeled?

☒ ☐ ☐ 18. Is there a line vacuum low switch wired to the master alarm panels?

Yes No ☒ ☐ a) Is the switch located on the patient side of the main valve, or source valve if there is no main valve?

☒ ☐ b) Is the switch connected with a demand check fitting?

☒ ☐ c) Is the demand check fitting gas specific?

☒ ☐ d) Is there a gauge installed next to the switch after source/mainline shutoff valve?

Location of switch: Back wall between pumps and compressors

COMMENTS:

16. LABELING IS INCORRECT COLOR CODING

18A. SWITCH PIPED TO WRONG SIDE OF SOURCE VALVE.

COPPER PIPING IS PAINTED

MANIFOLD ROOM

SOURCE LOCATION EVALUATION

Location of manifold room: West end near water chillers

Manifolds located in room:

☐ Oxygen ☒ Nitrogen ☐ Medical Air ☐ Carbon Dioxide ☒ Nitrous Oxide ☐ Instrument Air

Yes No N/A ☒ ☐ ☐ 1. Is the location used ONLY for storage of non-flammable gases? [5.1.3.2.3]

☒ ☐ ☐ 2. Is the location kept free of flammable materials, flammable gas cylinders, and flammable liquid containers? [5.1.3.2.4]

☒ ☐ ☐ 3. Is the location separate from mechanical equipment (i.e., air compressors, vacuum pumps, diesel fuel pumps)? [5.1.3.3.1.4]

☒ ☐ ☐ 4. Is location access restricted to authorized personnel only and adequately secured against tampering? [5.1.3.3.2 (2)]

☒ ☐ ☐ 5. Is the location free of open electrical contacts or transformers? [5.1.3.3.1.6 (4)]

☒ ☐ ☐ 6. Are electrical wall fixtures at least 5 ft. above floor or protected? [5.1.3.3.2 (10)]

☒ ☐ ☐ 7. Is the location protected from sources of heat exceeding 130°F? [5.1.3.3.1.7]

☒ ☐ ☐ 8. Are cylinders protected against accumulation of ice and snow or continuous exposure to direct rays of the sun? [11.6.5.4 (2-3)]

☐ ☐ ☒ 9. Are indoor locations constructed of materials with a minimum of 1-hour fire resistance rating? [5.1.3.3.2 (4)]

☐ ☐ ☒ 10. Does the manifold room employ natural ventilation? [5.1.3.5.6.1 (4)] Yes No ☐ ☐ a) Are there a minimum of two openings on an exterior wall?

☐ ☐ b) Are the openings located a foot from the floor and a foot from the ceiling?

☐ ☐ ☒ 11. Is the location vented outside by means of a dedicated mechanical ventilation system for indoor medical gas systems that don’t meet natural ventilation requirements?

[9.3.7.5.3]

Yes No ☐ ☐ a) Does the vent draw air from within one foot of the floor? [9.3.7.5.3.3] ☐ ☐ b) Is the exhaust fan connected to essential power? [9.3.7.5.3.4]

☒ ☐ ☐ 12. Is the appropriate door sign based on medical gasses permanently posted on the door? [5.1.3.1.8 or 5.1.3.1.9]

☒ ☐ ☐ 13. Are the cylinders secured with racks, chains, or other fastenings per OSHA standards?

[5.1.3.3.2 (7)]

☒ ☐ ☐ 14. Are the manifolds, valves, and piping protected against physical damage from movement of cylinders and equipment? [5.1.3.3.2 (1)]

☐ ☒ ☐ 15. Do relief valves vent to the outside, except for medical air systems less than 3000 cu ft? [5.1.3.5.6.1 (4)]

Yes No ☐ ☐ a) Is the relief valve discharge turned down and screened to prevent entry of rain, snow, or vermin? [5.1.3.5.6.1 (8)] ☒ ☐ b) Is the relief valve vent piping ASTM B-819 medical gas tube? [5.1.3.5.6.2] ☒ ☐ c) Are joints in relief valve vent piping brazed or Lokring? [5.1.3.5.6.2] ☒ ☐ d) Is relief valve vent piping labeled to distinguish from medical gas pipelines? [5.1.3.5.6.4]

COMMENTS

15. NITROGEN DOES NOT HAVE RELIEF VENT PIPING

15A. VENT PIPING DISCHARGE NOT FOUND

Nitrous Oxide Manifold

SOURCE EVALUATION DATA

Location of manifold: Bottle Room Area Served: Facility Manifold Manufacturer: Amico Model Number: M3A4-DL-HHH-U-N2O Serial Number: 20200403-0162 # Of cylinders Left Bank: 6 # Of cylinders Right Bank: 6 Main line pressure: 52 psi Gauge range: 0-100psi Left bank pressure/status: 650 psi / In Use Gauge range: 0-4,000psi Right bank pressure/status: 700 psi / Ready Gauge range: 0-4,000psi

Yes No N/A ☒ ☐ ☐ 1. Are final line regulators duplexed with isolation valves upstream of each regulator and shutoff valves or check valves downstream? [5.1.3.5.5.1 (1-2)] Yes No ☒ ☐ a) Is the manifold supplied with a heater or protected from temperatures lower than 20⁰F? [5.1.3.3.18] ☒ ☐ b) Is the manifold supplied by a recognized manufacturer? [5.1.3.5.1]

☒ ☐ ☐ 2. Are gauges downstream of each regulator present? [5.1.3.5.5.1 (3)]

☒ ☐ ☐ 3. Is a relief valve set at 50% above normal line pressure, located between each regulator and the source valve? [5.1.3.5.6.3 (1-2)]

Yes No ☐ ☐ a) Do relief valves vent to the outside, except for medical air systems less than 3000 cu ft? [5.1.3.5.6.1 (4)] ☐ ☐ b) Is the relief valve discharge turned down and screened to prevent entry of rain, snow, or vermin? [5.1.3.5.6.1 (8)] ☒ ☐ c) Is the relief valve vent piping ASTM B-819 medical gas tube? [5.1.3.5.6.2]

☒ ☐ d) Are joints in relief valve vent piping brazed or Lokring? [5.1.3.5.6.2] ☒ ☐ e) Is relief valve vent piping labeled to distinguish from medical gas pipelines?

[5.1.3.5.6.4] ☒ ☐ ☐ 4. Does each cylinder bank contain at least an average days’ (24 hours) supply with a minimum of 2 cylinders? [5.1.3.5.10.4 (1)]

☒ ☐ ☐ 5. Is manifold changeover from primary to secondary automatic? [5.1.3.5.10.5]

☒ ☐ ☐ 6. Is there an actuating switch present to indicate when changeover occurs from Primary to

Secondary? [5.1.3.5.10.6] Yes No ☒ ☐ a) Is there a visual indicating local signal present? [5.1.3.5.10.6] ☒ ☐ b) Is it wired to the master alarm? [5.1.3.5.10.6]

☒ ☐ ☐ 7. Do the header bars contain required pigtails with check valves? [5.1.3.5.9 (7)]

☒ ☐ ☐ 8. Is manifold supplied/built by a recognized medical equipment supplier/manufacturer?

[5.1.3.5.1]

☒ ☐ ☐ 9. Are operating and maintenance instructions available?

☒ ☐ ☐ 10. Does a periodic inspection and maintenance program exist for source equipment and alarms? [5.1.14.2.2.2]

☒ ☐ ☐ 11. Is there a high/low line pressure switch on the main line? [5.1.9.2.4 (7)]

Yes No ☒ ☐ a) Is it wired to the master alarm? [5.1.9.2.4 (7)] ☒ ☐ b) Is the switch located on the patient side of the main valve, or source valve if there is no main valve? [5.1.9.2.5] ☒ ☐ c) Is the switch connected with a gas specific demand check fitting? [5.1.8.2.3] ☒ ☐ d) Is there a gauge installed next to the switch after the source/mainline shutoff valve? [5.1.8.2.2 (1)] Location of switch: Just inside energy plant ☒ ☐ ☐ 12. Is the source valve installed in the immediate vicinity of the source equipment? [5.1.4.4]

Yes No ☒ ☐ a) Is it labeled? [5.1.11.2]

☒ ☐ ☐ 13. Is the manifold equipment free of leakage?

COMMENTS:

3A VENT LINE DISCHARGES IN AN UNKNOWN LOCATION

3B CANNOT DETERMINE IF VENT LINE IS SCREENED

11D MAIN LINE PRESSURE SWITCH IS LOCATED UPSTREAM OF MAIN VALVE

Nitrogen Manifold

SOURCE EVALUATION DATA

Location of manifold: Bottle room Area Served: Facility Manifold Manufacturer: Western Innovator Model Number: FHM2HP-7-6 Serial Number: 36498 # Of cylinders Left Bank: 6 # Of cylinders Right Bank: 6 Main line pressure: 181 psi Gauge range: Digital Left bank pressure/status: 687 psi/In service Gauge range: Digital Right bank pressure/status: 1959 psi/Ready Gauge range: Digital

Yes No N/A ☒ ☐ ☐ 1. Are final line regulators duplexed with isolation valves upstream of each regulator and shutoff valves or check valves downstream? [5.1.3.5.5.1 (1-2)] Yes No ☒ ☐ a) Is the manifold supplied by a recognized manufacturer? [5.1.3.5.1]

☒ ☐ ☐ 2. Are gauges downstream of each regulator present? [5.1.3.5.5.1(3)]

☒ ☐ ☐ 3. Is a relief valve set at 50% above normal line pressure, located between each regulator and the source valve? [5.1.3.5.6.3 (1-2)]

Yes No ☐ ☒ a) Do relief valves vent to the outside, except for medical air systems less than 3000 cu ft? [5.1.3.5.6.1 (4)] ☐ ☐ b) Is the relief valve discharge turned down and screened to prevent entry of rain, snow, or vermin? [5.1.3.5.6.1 (8)] ☐ ☐ c) Is the relief valve vent piping ASTM B-819 medical gas tube? [5.1.3.5.6.2]

☐ ☐ d) Are joints in relief valve vent piping brazed or Lokring? [5.1.3.5.6.2] ☐ ☐ e) Is relief valve vent piping labeled to distinguish from medical gas pipelines?

[5.1.3.5.6.4] ☒ ☐ ☐ 4. Does each cylinder bank contain at least an average days’ (24 hours) supply with a minimum of 2 cylinders? [5.1.3.5.10.4 (1)]

☒ ☐ ☐ 5. Is manifold changeover from primary to secondary automatic? [5.1.3.5.10.5]

☒ ☐ ☐ 6. Is there an actuating switch present to indicate when changeover occurs from Primary to

Secondary? [5.1.3.5.10.6] Yes No ☒ ☐ a) Is there a visual indicating local signal present? [5.1.3.5.10.6] ☒ ☐ b) Is it wired to the master alarm? [5.1.3.5.10.6]

☒ ☐ ☐ 7. Do the header bars contain the required pigtails with check valves? [5.1.3.5.9 (7)]

☒ ☐ ☐ 8. Is manifold supplied/built by a recognized medical equipment supplier/manufacturer?

[5.1.3.5.1]

☒ ☐ ☐ 9. Are operating and maintenance instructions available?

☒ ☐ ☐ 10. Does a periodic inspection and maintenance program exist for source equipment and alarms? [5.1.14.2.2.2]

☒ ☐ ☐ 11. Is there a high/low line pressure switch on the main line? [5.1.9.2.4 (7)]

Yes No ☒ ☐ a) Is it wired to the master alarm? [5.1.9.2.4 (7)] ☐ ☒ b) Is the switch located on the patient side of the main valve, or source valve if there is no main valve? [5.1.9.2.5] ☒ ☐ c) Is the switch connected with a gas specific demand check fitting? [5.1.8.2.3] ☒ ☐ d) Is there a gauge installed next to the switch after the source/mainline shutoff valve? [5.1.8.2.2 (1)] Location of switch: Just inside the energy plant ☒ ☐ ☐ 12. Is the source valve installed in the immediate vicinity of the source equipment? [5.1.4.4]

Yes No ☒ ☐ a) Is it labeled? [5.1.11.2]

☒ ☐ ☐ 13. Is the manifold equipment free of leakage?

COMMENTS:

3A MANIFOLD VENTS INTO BOTTLE ROOM. THERE IS NO VENT PIPING.

11D MAIN LINE PRESSURE IS LOCATED UPSTREAM OF MAIN VALVE

MASTER ALARM PANEL #1

LOCATION: BOILER CONTROL ROOM BLDG 100 POWER LIGHT FUNCTIONAL: YES

MANUFACTURER: TRI-TECH

MODEL: MED TOUCH

ALARM TESTED SENSOR

LOCATION

SET

POINTS

VISUAL

INDICATOR

AUDIBLE

INDICATOR

LABEL COMMENTS

OXYGEN

PRIMARY LIQUID LEVEL LOW TESTED BY OWNER

SECONDARY IN USE TESTED BY OWNER

SECONDARY LIQUID LOW TESTED BY OWNER

SECONDARY LOW PRESSURE TESTED BY OWNER

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

MEDICAL AIR

DEW POINT HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

CARBON MONOXIDE HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

LAG PUMP IN USE PASS PASS PASS PASS PASS

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

VACUUM

LINE PRESSURE LOW PASS PASS PASS PASS PASS

LAG PUMP IN USE PASS PASS PASS PASS PASS

NITROUS OXIDE

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

RESERVE IN USE PASS PASS PASS PASS PASS

NITROGEN

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

RESERVE IN USE PASS PASS PASS PASS PASS

CARBON DIOXIDE

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

RESERVE IN USE PASS PASS PASS PASS PASS

COMMENTS: PRESSURE SET POINTS TESTED AT 20% ABOVE AND 20% BELOW DESIGNATED OPERATING PRESSURES

MASTER ALARM PANEL #2

LOCATION: PBX OFFICE BLDG 100 POWER LIGHT FUNCTIONAL: YES

MANUFACTURER: TRI-TECH

MODEL: MED TOUCH

ALARM TESTED SENSOR

LOCATION

SET

POINTS

VISUAL

INDICATOR

AUDIBLE

INDICATOR

LABEL COMMENTS

OXYGEN

PRIMARY LIQUID LEVEL LOW TESTED BY OWNER

SECONDARY IN USE TESTED BY OWNER

SECONDARY LIQUID LOW TESTED BY OWNER

SECONDARY LOW PRESSURE TESTED BY OWNER

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

MEDICAL AIR

DEW POINT HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

CARBON MONOXIDE HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

LAG PUMP IN USE PASS PASS PASS PASS PASS

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

VACUUM

LINE PRESSURE LOW PASS PASS PASS PASS PASS

LAG PUMP IN USE PASS PASS PASS PASS PASS

NITROUS OXIDE

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

RESERVE IN USE PASS PASS PASS PASS PASS

NITROGEN

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

RESERVE IN USE PASS PASS PASS PASS PASS

CARBON DIOXIDE

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

RESERVE IN USE PASS PASS PASS PASS PASS

COMMENTS: PRESSURE SET POINTS TESTED AT 20% ABOVE AND 20% BELOW DESIGNATED OPERATING PRESSURES

MASTER ALARM PANEL #3

LOCATION: PBX OFFICE BLDG 101 POWER LIGHT FUNCTIONAL: YES

MANUFACTURER: TRI-TECH

MODEL: MED TOUCH

ALARM TESTED SENSOR

LOCATION

SET

POINTS

VISUAL

INDICATOR

AUDIBLE

INDICATOR

LABEL COMMENTS

MEDICAL AIR

DEW POINT HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

CARBON MONOXIDE HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

LAG PUMP IN USE PASS PASS PASS PASS PASS

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

VACUUM

LINE PRESSURE LOW PASS PASS PASS PASS PASS

LAG PUMP IN USE PASS PASS PASS PASS PASS

COMMENTS: PRESSURE SET POINTS TESTED AT 20% ABOVE AND 20% BELOW DESIGNATED OPERATING PRESSURES

MED AIR DEW POINT HIGH AND CO HIGH ARE NOT MONITORED

MASTER ALARM PANEL #4

LOCATION: PBX OFFICE BLDG 101 POWER LIGHT FUNCTIONAL: YES

MANUFACTURER: TRI-TECH

MODEL: MED TOUCH

ALARM TESTED SENSOR

LOCATION

SET

POINTS

VISUAL

INDICATOR

AUDIBLE

INDICATOR

LABEL COMMENTS

MEDICAL AIR

DEW POINT HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

CARBON MONOXIDE HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

LAG PUMP IN USE PASS PASS PASS PASS PASS

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

VACUUM

LINE PRESSURE LOW PASS PASS PASS PASS PASS

LAG PUMP IN USE PASS PASS PASS PASS PASS

MASTER ALARM PANEL #5

LOCATION: MECHANICAL ROOM BLDG 101 POWER LIGHT FUNCTIONAL: YES

MANUFACTURER: TRI-TECH

MODEL: MED TOUCH

ALARM TESTED SENSOR

LOCATION

SET

POINTS

VISUAL

INDICATOR

AUDIBLE

INDICATOR

LABEL COMMENTS

MEDICAL AIR

DEW POINT HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

CARBON MONOXIDE HIGH PASS PASS FAIL FAIL FAIL NOT MONITORED

LAG PUMP IN USE PASS PASS PASS PASS PASS

LINE PRESSURE HIGH PASS PASS PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

VACUUM

LINE PRESSURE LOW PASS PASS PASS PASS PASS

LAG PUMP IN USE PASS PASS PASS PASS PASS

VALVES

ALARM TESTED AREA OF CONTROL LOCATION SECURITY LABELING ACCESS LEAK TEST

OXYGEN

SOURCE VALVE Facility Bulk Pad Pass Pass Pass Pass MAIN VALVE Facility Boiler

Plant Pass Pass Pass Pass

EOSC Facility Outside Energy Plant

Pass Pass Pass Pass

MEDICAL AIR

SOURCE VALVE Facility Boiler

Plant Pass Pass Pass Pass

VACUUM

SOURCE VALVE Facility Boiler

Plant Pass Pass Pass Pass

NITROUS OXIDE

SOURCE VALVE Facility Manifold

Cage Pass Pass Pass Pass

NITROGEN

SOURCE VALVE Facility Manifold

Cage Pass Pass Pass Pass

LOCATION OF VALVE IS VERIFIED TO BE CORRECT FOR THE DESIGNATED AREA OF CONTROL. SECURITY OF VALVES ARE VERIFIED THE VALVE ARE IN AND

SECURE AREA AND ARE LOCKED OR LATCHED IN THEIR OPERATING POSITION. LABELING IS VERIFIED TO BE ACCURATE TO THE DESIGNATED AREA OF

CONTROL. ACCESS OF VALVES IS VERIFIED THAT VALVES CAN BE SAFELY REACHED FOR MAINTENANCE OPERATIONS.

Additional comments:

Zone Valve Oxygen Med Air Vacuum N2O WAGD N2 CO2

Gauge reading 55 psi 52 psi 20"Hg Pipe size 1-1/2" 1" 3" Labeling Pass Pass Pass Leak Test Pass Pass Pass Area Alarm Panel Oxygen Med Air Vacuum N2O WAGD N2 CO2

Pressure reading 54 psi 49 psi 22"Hg Audible Indicator ± 20% Pass Pass Pass Visual Indicator ± 20% Pass Pass Pass Labeling Pass Pass Pass Outlets/Inlets Oxygen Med Air Vacuum N2O WAGD N2 CO2

Pressure 50 psi 49 psi 20"Hg Flow Rate: > 6.05 SCFM Pass Pass Pass Concentration 100% O2 21% O2 N/A

Room Number Qty Qty Qty Qty Qty Qty Qty Test Result:

Room 108 (1) Boom 2 2 4 Pass Room 108 (1) Wall 2 2 4 Pass Room 109 (2) Boom 2 2 4 Pass Room 109 (2) Wall 2 2 4 Pass Room 111 (3) Boom 2 2 4 Pass Room 111 (3) Wall 2 2 4 Pass Room 114 (4) Boom 2 2 4 Pass Room 114 (4) Wall 2 2 4 Pass Room 116 (5) Boom 2 2 4 Pass Room 116 (5) Wall 2 2 4 Pass Room 117 (6) Boom 2 2 4 Pass Room 117 (6) Wall 2 2 4 Pass Room 119 (7) Boom 2 2 4 Pass Total # outlets/inlets 26 26 52 0 0 0 0

Observations:

Notes:

Notes:

Manufacturer: Chemetron

Location: Nurses station near room 13

Rooms Served: 108, 109, 111, 114, 116, 117, 119-121 124, 127 129-135 Notes:

Manufacturer: Chemetron Switch location: Downstream of ZVB

Manufacturer: Chemetron Flexible Connectors Inspected: N/A

Outlet Model : Series 400 Latch Style: Chemetron Latch

Facility: Seattle VA Medical Center Date: 23 April 2024

Bldg: 100 Technician:

Floor: 4th Unit: 4 MICU

Location: Next to zone valve box

Outlets/Inlets Oxygen Med Air Vacuum N2O WAGD N2 CO2

Pressure 50 psi 49 psi 20"Hg Flow Rate: >6.0 SCFM Pass Pass Pass Concentration 100% O2 21% O2 N/A

Room Number Qty Qty Qty Qty Qty Qty Qty Test Result:

Room 119 (7) Wall 2 2 4 Pass Room 120 (8) Boom 2 2 4 Pass Room 120 (8) Wall 2 2 4 Pass Room 121 (9) Boom 2 2 4 Pass Room 121 (9) Wall 2 2 4 Pass Room 124 (10) Boom 2 2 4 Pass Room 124 (10) Wall 2 2 4 Pass Room 127 (11) Boom 2 2 4 Pass Room 127 (11) Wall 2 2 4 Pass Room 129 (12) Boom 2 2 4 Pass Room 129 (12) Wall 2 2 4 Pass Room 130 (13) Boom 2 2 4 Not Tested Room 130 (13) Wall 2 2 4 Not Tested Room 131 (14) Boom 2 2 4 Pass Room 131 (14) Wall 2 2 4 Pass Room 132 (15) Boom 2 2 4 Pass Room 132 (15) Wall 2 2 4 Pass Room 133 (16) Boom 2 2 4 Pass Room 133 (16) Wall 2 2 4 Pass Room 134 (17) Boom 2 2 4 Pass Room 134 (17) Wall 2 2 4 Pass Room 135 (18) Boom 2 2 4 Pass Room 135 (18) Wall 2 2 4 Pass

Total # outlets/inlets 46 46 92 0 0 0 0

Stop Precaution Stop Precaution

Observations:

Floor: 4th Unit: 4 MICU

Notes:

Facility: Seattle VA Medical Center Date: 23 April 2024

Bldg: 100 Technician:

Manufacturer: Chemetron Flexible Connectors Inspected: N/A

Outlet Model : Series 400 Latch Style: Chemetron Latch

Gauge reading

Pipe size

Labeling Pass Pass Leak Test Pass Pass Area Alarm Panel Oxygen Med Air Vacuum N2O WAGD N2 CO2

Pressure reading 55 psi 49 psi 22"Hg Audible Indicator ± 20% Pass Pass Pass Visual Indicator ± 20% Pass Pass Pass Labeling Pass Pass Pass Outlets/Inlets Oxygen Med Air Vacuum N2O WAGD N2 CO2

Pressure 50 psi 49 psi 20"Hg Flow Rate: > 3.5 SCFM Pass Pass Pass Concentration 100% O2 21% O2 N/A

Room Number Qty Qty Qty Qty Qty Qty Qty Test Result:

4B 119 2 2 3 Pass 4B 121 2 2 3 Pass 4B 123 2 2 3 Pass 4B 124 2 2 3…