S02 0001 Attch 2 2024 American Lake Medical Gas Inspection Report.pdf

American Lake VA Medical Center

9600 Veterans Dr. Lakewood WA 98493

24 April 2024

American Lake VA Medical Center David Pape 9600 Veterans Dr.

Joint Base Lewis McCord, WA 98493

Re: Cat 1 annual medical gas inspection

1.0 Letter of verification

An annual medical gas inspection of the source equipment, master alarm panels, valving hierarchy, labeling and identification, and patient care inlets and outlets has been completed.

Criteria for this testing is based on the NFPA-99, 2021 edition, chapter 5, Standard for Health Care Facilities, the ASSE 6000 2018 edition, JC EC.02.05.09, AIA, and CGA guidelines.

This annual medical gas inspection was found to be consistent with the requirements of the above-mentioned publications with noted exceptions.

Date

Copies to: KLB (1)

DP (1)

24 April 2024 http://www.medgas.com/

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

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 leased by:

2. Bulk site is inspected by:

3. Site maintenance and safeties are managed by:

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

3.4 Medical gas manifolds – O2, MA, N2O

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 + 125-0256 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 Ashton Steely Apprentice YES Jeff Champagne Lead ASSE 6040 3/2027 YES

6.0 Outlets/Inlets tested

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

Oxygen Medical Air

Vacuum Nitrous Oxide

Tested 145 55 152 4 Not Tested* 2 0 2 0 Total 147 55 154 4

*Not tested is an estimated count of outlets and inlets

American Lake VA Medical Center 24 April 2024

MEDICAL GAS & VACUUM REPORT KEY

FACILITY CONTACT: David Pape, 253-310-7063, David.pape@va.gov ADDRESS: 9600 Veterans dr. SW, Joint Base Lewis-McCord, WA 98493 MedGas.com 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 O = OXYGEN

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

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

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

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

CROSS CONNECTIONS O, A, V, NO 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 MedGas.com 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.

SIGNATURE:____________________________________ DATE: _________________ 24 April 2024

American Lake VA Hospital Medical Center 24 April 2024

SUMMARY REPORT

OBSERVATIONS FOR UPGRADES – NOT A RECOMMENDATION

Location Problem/Deficiency Suggestion Reference Corrected by & date

SOUTH PARKING LOT

BULK PAD

TWO PATHS OFF EGRESS ARE NOW REQUIRED TO EXIT

THE BULK PAD.

ADD GATE TO OPPOSITE SIDE

BUILDING 85

MECHANICAL ROOM

NO DEW POINT SAMPLE PORT ON MED AIR

COMPRESSOR

HAVE SAMPLE PORT INSTALLED 5.1.3.6.3.9(K)

BUILDING 85

MECHANICAL ROOM

MED AIR DEMAND CHECK ON PRESSURE SWITCH NOT

OPERATING AS INTENDED, AIR STILL ESCAPES WHEN

DETACHED

REPLACE DEMAND CHECK 5.1.8.2.3

BUILDING 85

MECHANICAL ROOM

NO PRESSURE SWITCH ON VACUUM AFTER SOURCE

VALVE

INSTALL PRESSURE SWITCH 5.1.8.2.2(1)

BLDG 85

MECHANICAL ROOM

DUE TO PUMP 2 NOT HOLDING PRESSURE

ALTERATION OF PUMPS IS NOT WORKING.

REPAIR OR REPLACE PUMP

BUILDING 85

MECHANICAL ROOM

VACUUM LAG IN USE IS NOT WIRED TO THE MASTER

ALARM

FURTHER INVESTIGATION REQUIRED

BUILDING 81

PED/SURG

MA AND N2O IS NOT IN USE HANDLES ARE

REMOVED.

NOT IN SERVICE

BLDG 85 MANIFOLD

RM

VENTS DISCHARGE OVER EGRESS RELOCATE VENT

BUILDING 81

COMMS CENTER

IS NOT RECEIVING SIGNAL FOR MASTER ALARMS

FROM BUILDINGS 200 AND 85.

OBSERVATION

Location Problem/Deficiency Suggestion Reference Corrected by & date

BLDG 200

MECHANICAL ROOM

VACUUM EXHAUST IS MISSING DRIP LEG ADD DRIP LEG TO EXHAUST 5.1.3.7.7.5

BUILDING 81

PED/SURG

MA AND N2O IS NOT IN USE HANDLES ARE

REMOVED.

NOT IN SERVICE

BUILDING 81 OR

SUITE BEDS 1-3

½” VACUUM PIPE UNDERSIZED. REPLACE VALVE WITH ¾” EXTENSIONS 5.1.10.11.1.3

BUILDING 81 OR

SUITE BEDS 1-3

ZVB BEHIND DOOR MOVE ZONE VALVE BOX FROM BEHIND DOOR. 5.1.4.6.1(4)

BUILDING 81 OR

SUITE BEDS 1-3

VACUUM AUDIBLE ALARM DID NOT SOUND REPLACE CIRCUIT BOARD OR REPLACE ALARM PANEL 5.1.9.4.6

BLDG 81 3RD FL IV

THERAPY STATION A

E

COVER DOES NOT COME OFF, CAN'T SEE VALVE SIZES REPLACE ZVB COVER

BLDG 81 3RD FL IV

THERAPY

MED AIR AND VACUUM ZONE VALVES ARE MISSING

GAUGES

REPLACE VALVES WITH ONES THAT HAVE GAUGE

PORTS AND INSTALL GAUGES

5.1.8.2.2(3)

BLDG 81 3RD FL IV

THERAPY

AIR IS THE WRONG COLOR. REPLACE WITH YELLOW MEDICAL AIR PLACARDS

BLDG 81 3RD FL GI

CLINIC

ROOM 350 LEFT VACUUM IS BROKEN REPAIR OR REPLACE VACUUM INLET

BUILDING 81 2ND

FLOOR DIAGNOSTIC

IMAGING

O2 VALVE LEAKS REPAIR O2 VALVE

BUILDING 81 2ND

FLOOR EKG

ZONE VALVE BOX DOES NOT SERVE OUTLETS OBSERVATION

BUILDING 85 114 NO ZONE VALVE FOR VACUUM INSTALL A ZONE VALVE FOR VACUUM 5.1.4.6.2(1)

BUILDING 200 C

POD

O2 VALVE LEAKS AT HANDLE REPLACE O2 VALVE 5.1.12.2.3.6

BUILDING 200 C

POD

VACUUM DISPLAY OUT OF RANGE REPLACE CIRCUIT BOARD 5.1.8.1.4

Location Problem/Deficiency Suggestion Reference Corrected by & date

BUILDING 200 A

POD

O2 GAUGE OUT OF RANGE REPLACE GAUGE 5.1.8.1.4

BUILDING 81

MANIFOLD ROOM

N2O VENT DISCHARGES OVER EGRESS RELOCATE VENT

BUILDING 85 THE TREATMENT ROOMS ARE CONTROLLED BY

SERVICE VALVES

INSTALL ZONE VALVES FOR THE TREATMENT ROOMS 5.1.4.6.1

Leased Bulk Oxygen

SOURCE EVALUATION

Location of bulk pad: South Parking Lot Area Served: Building 81 Bulk supplier is: Air Liquide Emergency phone number: 206-461-9324 Main line pressure: 50 psi

* Leased Bulk Equipment is inspected annually by the equipment owners. MedGas.com 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 is 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)]

Yes No N/A ☒ ☐ ☐ 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:

TWO PATHS OFF EGRESS ARE NOW REQUIRED TO EXIT THE BULK PAD.

Leased Bulk Oxygen

Location of bulk pad: Near Loading Dock Area Served: Building 200 Bulk supplier is: Praxair Emergency phone number: 1-800-772-9247 Main line pressure: 50 psi

* Leased Bulk Equipment is inspected annually by the equipment owners. MedGas.com 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 is 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:

Medical Air Compressor

FOR INFORMATION ONLY

OUT OF SERVICE

LOCATION OF COMPRESSOR: BUILDING 200 MECHANICAL ROOM AREA SERVED: BUILDING 200

UNIT MANUFACTURER: CHEMETRON TECH SUPPORT PHONE: 1-800-444-3954

UNIT MODEL NUMBER: DOS020-80BDD SERIAL NUMBER: (H) 9/18/2009-4449128-28

COMPRESSOR MANUFACTURER: POWEREX HP: 2 VOLTAGE: 460

COMPRESSOR DATA MODEL # SERIAL # 2023 HOURS 2024 HOURS

UNIT 1 SLAE03E JB1239 4,048 NO POWER

UNIT 2 SLAE03E JB1245 4,060 NO POWER

UNIT 3

UNIT 4

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

THE LEAD COMPRESSOR IS ON AT PSI AND OFF AT 115 PSI LAG IS ON AT PSI AND OFF AT PSI

DEW POINT READING ⁰F @ PSI

DP MANUFACTURER: VAISALA DP MODEL # DMT142 SERIAL # E2830018

CARBON MONOXIDE READING:

CO MANUFACTURER: ENMET CO MODEL # CO-GUARD SERIAL # 300-1009

DRYER MANUFACTURER: PARKER DRYER MODEL # K-MT 1 RX SERIAL # 09/58517

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

DEW POINT: OXYGEN PERCENTAGE:

HYDROCARBONS (METHANE): CARBON MONOXIDE:

HYDROCARBONS (CHLOROFORM): CARBON DIOXIDE:

TEMPERATURE AMBIENT @ COMPRESSOR INLET @ HEAT EXCHANGER

UNIT 1 °F °F °F

UNIT 2 °F °F °F

UNIT 3

UNIT 4

TIME: CUT IN/80PSI UNIT 1: SECONDS UNIT 2: 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.)

Yes No N/A ☒ ☐ ☐ 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:

THIS UNIT IS POWERED DOWN AND LOCKOUT TAG OUT AND PLACED OUT OF SERVICE.

Medical Air Compressor

LOCATION OF COMPRESSOR: BUILDING 85 MECHANICAL ROOM AREA SERVED: BUILDING 85

UNIT MANUFACTURER: HILL-ROM TECH SUPPORT PHONE: 1-800-444-3954

UNIT MODEL NUMBER: 6916-9050-Z06C SERIAL NUMBER: 6CVAG-029

COMPRESSOR MANUFACTURER: HILL-ROM HP: 15 VOLTAGE: 460

COMPRESSOR DATA MODEL # SERIAL # 2022 HOURS 2023 HOURS

UNIT 1 WTVS55A F0000388 1,175 1,209

UNIT 2 WTVS55A F0000394 882 905

UNIT 3

UNIT 4

THE MEDICAL AIR MAIN LINE PRESSURE IS: 74 PSI GAUGE RANGE IS: 0-100 PSI

THE LEAD COMPRESSOR IS ON AT 90 PSI AND OFF AT 100 PSI LAG IS ON AT 80 PSI AND OFF AT 100 PSI

DEW POINT READING 89⁰F @ 74 PSI

DP MANUFACTURER: HILL-ROM DP MODEL # SERIAL # ILLEGIBLE

CARBON MONOXIDE READING: 0 PPM

CO MANUFACTURER: HILL-ROM CO MODEL # SERIAL # ILLEGIBLE

DRYER MANUFACTURER: HILL-ROM DRYER MODEL # HFH65V SERIAL # HFH65VE

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

DEW POINT: OXYGEN PERCENTAGE:

HYDROCARBONS (METHANE): CARBON MONOXIDE:

HYDROCARBONS (CHLOROFORM): CARBON DIOXIDE:

TEMPERATURE AMBIENT @ COMPRESSOR INLET @ HEAT EXCHANGER

UNIT 1 70°F 80°F 86°F

UNIT 2 70°F 77°F 80°F

UNIT 3

UNIT 4

TIME: CUT IN/80PSI UNIT 1: 35 SECONDS UNIT 2: 30 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)]

☒ ☐ ☐ 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:

17. NO DEW POINT SAMPLE PORT

DEW POINT SENSOR PROBABLY NEEDS REPLACED.

Surgical Vacuum

SOURCE EVALUATION DATA

LOCATION OF VACUUM PUMP: BUILDING 81 MECHANICAL ROOM AREA SERVED: BUILDING 81

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

UNIT MODEL NUMBER: CPD-V5-208 SERIAL NUMBER: 46222203

PUMP MANUFACTURER: ELMO RIETSCHLE HP: 5 VOLTAGE: 208

VACUUM PUMP DATA MODEL # SERIAL # 2023 HOURS 2024 HOURS

UNIT 1 V-VC 100(21) SC10197838003/2014 1,487 3,740

UNIT 2 V-VC 100 (21) SC10197838001/2014 1,486 3,739

UNIT 3

UNIT 4

THE VACUUM MAIN LINE PRESSURE IS: 23”HG GAUGE RANGE IS: 0-30HG

THE LEAD PUMP IS ON AT 20” HG AND OFF AT 26” HG LAG IS ON AT 19” HG AND OFF AT 22” HG

TEMPERATURES AMBIENT OIL SITE GLASS OIL FILTER PUMP EXHAUST

UNIT 1 89°F N/A N/A 121°F

UNIT 2 89°F N/A N/A 114°F

UNIT 3

UNIT 4

TIME CUT IN/22”HG 107 SECONDS 126 SECONDS

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

☒ ☐ ☐ 2. Is the entire Building 81 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 upstream of Main Valve

LOCATION OF VACUUM PUMP: BUILDING 200 MECHANICAL ROOM AREA SERVED: BUILDING 200

UNIT MANUFACTURER: CHEMETRON TECH SUPPORT PHONE: 1 800-444-3954

UNIT MODEL NUMBER: DLV030-120T SERIAL NUMBER: (H) 9/23/2009-4449128-30

PUMP MANUFACTURER: BUSCH HP: 3 VOLTAGE: 460

VACUUM PUMP DATA MODEL # SERIAL # 2023 HOURS 2024 HOURS

UNIT 1 RC0063.E5Z6.1023 U093704420 20,362 20,899

UNIT 2 RC0063.E5Z6.1023 U093604309 20,626 21,242

UNIT 3

UNIT 4

THE VACUUM MAIN LINE PRESSURE IS: 21”HG GAUGE RANGE IS: 0-30HG

THE LEAD PUMP IS ON AT 18” HG AND OFF AT 26” HG LAG IS ON AT 15” HG AND OFF AT 23” HG

TEMPERATURES AMBIENT OIL SITE GLASS OIL FILTER PUMP EXHAUST

UNIT 1 67°F 90°F 110°F 90°F

UNIT 2 67°F 76°F 82°F 77°F

UNIT 3

UNIT 4

TIME CUT IN/22”HG 600 SECONDS 600 SECONDS

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

☒ ☐ ☐ 2. Is the entire Building 81 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

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 upstream of Main Valve

COMMENTS:

14C. NO DRIP LEG ON EXHAUST.

LOCATION OF VACUUM PUMP: BASEMENT MECHANICAL ROOM AREA SERVED: BUILDING 85

UNIT MANUFACTURER: DECKER TECH SUPPORT PHONE: 1 800-444-3954

UNIT MODEL NUMBER: Rml145s2-40-ES SERIAL NUMBER: 32416

PUMP MANUFACTURER: DECKER HP:10 VOLTAGE: 460

VACUUM PUMP DATA MODEL # SERIAL # 2023 HOURS 2024 HOURS

UNIT 1 RVL145HH-16 34550 13,390 16,549

UNIT 2 RVL145HH-16 1118N053 10,239 16,548

UNIT 3

UNIT 4

THE VACUUM MAIN LINE PRESSURE IS: 20 ”HG GAUGE RANGE IS: 0-30HG

THE LEAD PUMP IS ON AT ” HG AND OFF AT ” HG LAG IS ON AT ” HG AND OFF AT ” HG

TEMPERATURES AMBIENT OIL SITE GLASS OIL FILTER PUMP EXHAUST

UNIT 1 77°F 187°F 195°F 160°F

UNIT 2 77°F 190°F 194°F 165°F

UNIT 3

UNIT 4

TIME CUT IN/22”HG COULD NOT TEST COULD NOT TEST

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

☒ ☐ ☐ 2. Is the entire Building 85 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

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:

COMMENTS:

18.NO PRESSURE SWITCH.

SINCE THIS IS DENTAL VACUUM PVC PIPING IS ACCEPTABLE

PUMP 2 DOES NOT HOLD PRESSURE AND PUMP 1 HAD TO CONTINUOUSLY BE ON TO KEEP UP. RECOMMEND FURTHER

TROUBLESHOOTING.

MANIFOLD ROOM

SOURCE LOCATION EVALUATION

Location of manifold room: 4th floor OR Suite

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?

☐ ☐ c) Are the openings a minimum of 72 in sq?

☒ ☐ ☐ 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.VENTS DISCHARGE OVER EGRESS

MANIFOLD ROOM

SOURCE LOCATION EVALUATION

Location of manifold room: Building 85 outside manifold room

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?

☒ ☐ c) Are the openings a minimum of 72 in sq?

☐ ☐ ☒ 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.VENTS DISCHARGE OVER EGRESS

Oxygen HP x HP Manifold

Location of manifold: Next to Outside Mechanical Room Area Served: BLDN 85 Dental Manifold Manufacturer: Hill-Rom Model Number: 68049040009 Serial Number: EBEAG0030 # Of cylinders Left Bank: 2 # Of cylinders Right Bank: 2 Main line pressure: 48 psi Gauge range: 0-100 PSI Left bank pressure/status: 1,400 PSI – Ready Gauge range: 0-3,000 PSI Right bank pressure/status: 1,300 PSI – In use Gauge range: 0-3,000 PSI

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)]

☒ ☐ ☐ 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] ☒ ☐ ☐ 3. 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)]

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

☒ ☐ ☐ 5. 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]

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

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

[5.1.3.5.1]

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

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

☒ ☐ ☐ 10. 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: downstream of source valve

☒ ☐ ☐ 11. 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]

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

Nitrous Oxide Manifold

Location of manifold: 4th floor manifold room Area Served: OR Suite Manifold Manufacturer: Beacon Medaes Model Number: 4107213325 Serial Number: HOP803586 # Of cylinders Left Bank: 3 # Of cylinders Right Bank: 3 Main line pressure: 50 psi Gauge range: 0-100 psi Left bank pressure/status: 625 psi/In Use Gauge range: 0-3,000 psi Right bank pressure/status: 750 psi/Ready Gauge range: 0-3,000 psi

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)]

☒ ☐ ☐ 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] ☒ ☐ ☐ 3. 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)]

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

☒ ☐ ☐ 5. 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]

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

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

[5.1.3.5.1]

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

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

☒ ☐ ☐ 10. 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: Downstream of source valve.

☒ ☐ ☐ 11. 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]

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

MASTER ALARM PANEL #1

LOCATION: BASEMENT MECHANICAL ROOM BLDG 81 POWER LIGHT FUNCTIONAL: YES

MANUFACTURER: TRI-TECH

MODEL: MED TOUCH

ALARM TESTED SENSOR

LOCATION

SET

POINTS

VISUAL

INDICATOR

AUDIBLE

INDICATOR

LABEL COMMENTS

OXYGEN

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

MASTER ALARM PANEL #2

LOCATION: COMMS CENTER BLDG 81 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

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

COMMENTS: Pressure set points tested at 20% above and 20% below designated operating pressures

IS NOT RECEIVING SIGNAL FOR MASTER ALARMS FROM BUILDINGS 200 AND 85.

MASTER ALARM PANEL #3

LOCATION: NITROUS MANIFOLD ROOM BLDG 81 POWER LIGHT FUNCTIONAL: YES

MANUFACTURER: TRI TECH

MODEL: MED TOUCH

ALARM TESTED SENSOR

LOCATION

SET

POINTS

VISUAL

INDICATOR

AUDIBLE

INDICATOR

LABEL COMMENTS

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

COMMENTS: Pressure set points tested at 20% above and 20% below designated operating pressures

MASTER ALARM PANEL #4

LOCATION: FRONT RECEPTIONIST DESK BLDG 200 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 NOT IN SERVICE

CARBON MONOXIDE HIGH NOT IN SERVICE

LAG PUMP IN USE NOT IN SERVICE

LINE PRESSURE HIGH NOT IN SERVICE

LINE PRESSURE LOW NOT IN SERVICE

VACUUM

LINE PRESSURE LOW PASS PASS PASS PASS PASS

LAG PUMP IN USE PASS PASS PASS PASS PASS

MASTER ALARM PANEL #5

LOCATION: BOILER ROOM BLDG 200 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 FAIL PASS PASS PASS

LINE PRESSURE LOW PASS PASS PASS PASS PASS

MEDICAL AIR

DEW POINT HIGH NOT IN SERVICE

CARBON MONOXIDE HIGH NOT IN SERVICE

LAG PUMP IN USE NOT IN SERVICE

LINE PRESSURE HIGH NOT IN SERVICE

LINE PRESSURE LOW NOT IN SERVICE

VACUUM

LINE PRESSURE LOW PASS PASS PASS PASS PASS

LAG PUMP IN USE PASS PASS PASS PASS PASS

MASTER ALARM PANEL #6

LOCATION: D-WING BY ZVB BLDG 200 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…