ARMC Central Plant Medical Vacuum System Replacement - HCAI TIO.pdf
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- Solicitation number
- ANE223-ANE2C-6171
- Issued by
- San Bernardino County, California
About this file
This is a Testing, Inspection, and Observation (TIO) Program document prepared for the California Department of Health Care Access and Information (HCAI) under the 2022 California Building Standards Code for an OSHPD 1 project. The document outlines the comprehensive testing, inspection, and observation requirements for the Arrowhead Regional Medical Center (ARMC) Central Plant Medical Vacuum System Replacement project, located at 400 N. Pepper Avenue in San Bernardino, California (Facility #17282, Project #S250159-36-00). The TIO program establishes mandatory verification protocols across multiple construction stages, with Stage 1 (Sequence 1) and Stage 2 (Sequence 3) designating specific inspection milestones. The program requires completion of plan review items, special inspections, field testing, and contractor verification reports prior to construction commencement and substantial compliance certification. HCAI field staff approval must be obtained before construction begins, with the document signed by Architect of Record Jeremy C. Welton, Structural Engineer of Record Tina W. Go (License #C28335), and project reviewer Allen Cheng, all dated March 20, 2025.
The TIO program mandates extensive testing and inspection requirements including structural tests (concrete and steel), electrical tests (insulation and torque connection verification), plumbing tests focused on medical gas and vacuum systems per NFPA 99-2021 standards, fire protection and life safety system testing per NFPA 72-2022, and comprehensive special inspections for concrete placement, admixtures, reinforcing steel, and field welding. The document requires an Inspector of Record (IOR) with continuous oversight of all construction work phases to ensure compliance with approved construction documents, applicable codes, referenced standards, and manufacturer specifications. All test and special inspection reports must be submitted by the responsible approved agencies to the IOR, hospital owner, architect in responsible charge, and structural engineer. The responsible approved agency and/or individual must be employed by the health facility, owner, or governing board authority per California Administrative Code Section 7-149(b). Verification compliance reports shall be signed by individuals performing special inspections in accordance with CAC 7-151(c), clearly stating whether work was performed in accordance with HCAI-approved documents and whether results indicate compliance.
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Testing, Inspection, and Observation Program 2022 California Building Standards Code - OSHPD 1
Colton County:
Stage Name
Sequence 1
Sequence 3
Construction shall not commence until the health facility has obtained from HCAI "TIO Program Approval".
(CAC Section 7-135(a)3)
The administration of the work of construction, including this TIO, shall be under the responsible charge of an architect and structural engineer. When a structural engineer is not substantially involved, the architect shall be solely responsible. Where neither structural nor architectural elements are substantially involved, a mechanical or electrical engineer registered in the branch of engineering most applicable to the project may be in responsible charge. (CAC 7-141(a))
Note: HCAI plan review staff must provide verification that the TIO program has been "Reviewed" prior to plan approval to confirm the applicability of the tests and inspections identified in the TIO program for work scope, building systems, and the construction materials shown in the design drawings. Field staff will issue subsequent "TIO Program Approval".
The "TIO Program Approval" from HCAI field staff must be obtained and included with the notice of start of construction required by CAC
Section 7-137(a)4) and 7-145(a)5.A)
CPC: California Plumbing Code
DESIGN PROFESSIONAL OF RECORD RESPONSIBILITY
Testing, Inspection, and Observation Stages Stage No. Stage Scope / Description
This program is prepared and submitted for an OSHPD 1 project. OSHPD 1 projects include all construction and remodel projects for: general acute care hospitals, acute psychiatric hospitals, and general acute care hospitals providing only acute medical rehabilitation center services (2022 CBC 1224.1).
SECTION A PROJECT INFORMATION
Street
Address:
400 N. Pepper Ave.
Facility Name:
17282 Arrowhead Regional Medical Center
Project #:
S250159-36-00
Facility #:
Record Name (Scope of Project): Medical Vacuum Pump Replacement
San BernardinoCity:
Abbreviations:
CAC: California Administrative Code AAMA: American Architectural Manufacturers Association
NFPA: National Fire Protection Association
FM: FM Approval Standards
DPOR: Design Professional of Record
CBC: California Building Code
CEC: California Electrical Code
CMC: California Mechanical Code
Version: R04.36
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-A1OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
TESTS
S a m p le s o f T e s t
In s p e c ti o n
R e p o rt c lu d e d
O P
A A
N o a n d
E x p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Individual)
C o m p li a n e
V ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
STRUCTURAL TESTS
x12 Concrete
B -C
X
Concrete
CBC 1705A.3, 1903A.6 & 1910A.1; ACI 318 1.9.1 &
26.4.1.1
Cementitious materials
TBD
B -C
X Concrete
CBC 1705A.3, 1903A.5; ACI 318 1.9.1 & 26.4.1.2
Aggregates/Reactive aggregates
TBD
B -C
X Concrete
CBC 1705A.3; ACI 318 26.4.1.4; ASTM C1602
Water
TBD
B -C
X Concrete
CBC 1705A.3 & 1905A.1.17; ACI 318 26.12
Strength test
TBD
B -C
X
Concrete
CBC 1705A.3 & 1910A.2; ACI 318 20.2, 25.4.5.1 &
26.6.1.2
Metal reinforcement (including welded wire fabric and headed rebar)
TBD
B -C
X
Post-installed anchors
CBC 1910A.5
Installation verification test (includes adhesive, shot pins and mechanical anchors)
TBD
x14 Steel
B -S
X
Steel
CBC Table 1705A.2.1 & 2202A.1
Testing of unidentified steel or identification test for structural steel and cold formed steel
TBD
ELECTRICAL TESTS
B -E
X Insulation Testing
CEC 110.7
TBD
B -E
X Torque Electrical Connections
CEC 110.3(B) & 110.14(D)
TBD
PLUMBING TESTS
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.2.1 thru 5.1.12.2.7
Installer performed tests
TBD
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.2.6.7 & 5.1.12.2.7.6
Witness of 24-hour standing pressure test
TBD
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.3.1.1 thru 5.1.12.3.1.5
System inspection prior to concealment/cover
TBD
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.3.2.1
Inspection
TBD
Stage 2: Sequence 3 Select with "X" or provide required OPAA information:
SECTION B
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
17282 S250159-36-00
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-B1 Stage 2OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
TESTS
S a m p le s o f T e s p e c ti o n
R e p o lu d e d
O P
A A
N o a p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Individual)
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
Stage 1: Sequence 1 Select with "X" or provide required OPAA information:
SECTION B
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
17282 S250159-36-00
B -P
X Existing Sewers and Drains
CPC 102.4.1, 105.3, & 712.0
Tested for conformance with requirements for new work
TBD
FIRE PROTECTION AND LIFE SAFETY SYSTEMS
B -F
P
X Fire Alarm
CFC 901.5 & CFC 907.7 NFPA 72-2022 §14.4
Acceptance and reacceptance testing
TBD
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-B2 Stage 1OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
ON-SITE SPECIAL
INSPECTIONS
S a m p le s o f T e s p e c ti o n
R e p o lu d e d
O P
A A
N o a p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Special Inspector)
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
STRUCTURAL SPECIAL INSPECTIONS
x12 Concrete
C -C
X Concrete
CBC 1705A.3; ACI-318 26.5.2 & 26.13
Placement of concrete
TBD
C -C
X Concrete
CBC 1705A.3; ACI-318 26.4.1.5
Admixtures
TBD
C -C
X Concrete
CBC 1705A.3; ACI-318 26.4
Mix design
TBD
C -C
X Concrete
CBC 1705A.3; ACI-318 26.13
Reinforcing steel & prestressing steel
TBD
C -C
X Concrete
CBC 1705A.3
CIP & post-installed anchors
TBD
x14 Steel
C -S
X Steel
CBC 1705A.2.5
Field welding
TBD
C -S
X Steel
AWS D1.1 3 & 4 & AWS D1.8 6.1
Field welding - WPS / WPQR
TBD
x18Nonstructural components, supports and attachments
C -N
X Plumbing, mechanical and electrical components
CBC 1705A.13.6
Anchorage, bracing, and vibration isolators
TBD
Stage 1: Sequence 1 Select with "X" or provide required OPAA information:
SECTION C
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-C1 Stage 1OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
OFF-SITE SPECIAL
INSPECTIONS
S a m p le s o f T e s p e c ti o n
R e p o lu d e d
O P
A A
N o a p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Special Inspector)
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
STRUCTURAL SPECIAL INSPECTIONS
x11 Concrete
D -C
X Concrete
CBC 1705A.3; ACI-318 26.4
Mix design
TBD
D -C
X Concrete
CBC 1705A.3.3
Batch plant inspection
TBD
Stage 2: Sequence 3 Select with "X" or provide required OPAA information:
SECTION D
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-D1 Stage 2OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
F o rm
R e q u ir e d
(S e le c t w it h
X
DOCUMENT NAME
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
Responsible Designer
Or
Installing Contractor
No Requirements for this Section of the TIO
SECTION E REQUIRED COMPLIANCE FORMS
Facility #: Project #:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-E1OSH-FD-303A (R04.36)
Facility #:
17282
PROJECT STAGE(S), MILESTONE, OR
INTERVAL
(Clearly indicate which Stage(s) apply to which Milestone/Interval)
GEOR AOR SEOR MEOR EEOR CONT IOR
SP
INSP
TEST
LAB
Clear all plan review Outstanding Items
List (OIL) Items
SEQUENCE 1 X X X X X X X X
SEQUENCE 3 X X X X X X X X
Installation of temporary equipment
Removal of temporary equipment
Substantial Compliance
(Remodel, Renovations, Maintenance projects, Equipment Replacement)
X X X X X X X X
Certificate of Occupancy
(New Buildings, Additions, Changes in
Occupancy)
Construction Final X X X X X X X X
ABBREVIATIONS: GEOR - Geotechnical Engineer of Record AOR - Architect of Record SEOR - Structural Engineer of Record
MEOR - Mechanical Engineer of Record EEOR - Electrical Engineer of Record CONT O/B - Contractor or Owner/Builder
SP. INSP - Special Inspector IOR - Inspector of Record Test Lab – Engr. For the approved agency
VERIFIED COMPLIANCE REPORT REQUIRED AS INDICATED
(Form HCAI-OSH-123)
(See “PERSONAL KNOWLEDGE” as defined in California Administrative Code, Section 7-151)
VERIFIED CONSTRUCTION INSPECTION AND OBSERVATION REPORTING
CONSTRUCTION VERIFICATION
Facility Name:
Arrowhead Regional Medical Center
SECTION F
REFERENCE
NUMBER
H C
A I/
F D
D U
S E
Project #:
S250159-36-00
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-F1OSH-FD-303A (R04.36)
SECTION G
Facility #: Facility Name:
17282 Arrowhead Regional Medical Center
INSPECTOR OF RECORD
CAC 7-141, 7-145 & 7-151
PERFORMED
OFF-SITE
Inspector of Record (IOR) Responsibility
INSPECTOR OF RECORD RESPONSIBILITIES. Per CAC 7-145: “The Inspector shall have personal knowledge, obtained by continuous inspection of all work of construction in all stages of its progress to ensure that the work is in accordance with the approved construction documents.” This includes applicable Codes, Referenced Standards, Listings and Manufacturer’s Installation Instructions applicable to the work shown in the approved construction documents. If a project has more than one inspector of record, the distribution of responsibilities for the work shall be clearly identified for each IOR per CAC 7-141(f). One IOR shall be designated as the ‘lead’ IOR per CAC 7-144(b). One IOR shall be assigned responsibility for “all other work” to make sure responsibility for the inspection of every part of the work is assigned.
SCOPE OF INSPECTION
Project #:
S250159-36-00
All other work
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-G1OSH-FD-303A (R04.36)
SECTION H
Facility #:
17282
Submitted By:
Architect/Engineer of Record (Signature) Date
Structural Engineer of Record (Signature) Date
TIO Program Reviewed by HCAI Plan Review Staff:
Note: HCAI plan review staff must provide verification that the TIO program has beeen "Reviewed" prior to plan approval to confirm the applicability of the tests and inspections identified in the TIO program for work scope, building systems, and the construction materials shown in the design drawings. Field staff will issue subsequent "TIO Program Approval".
HCAI REVIEWED
NOTE: When a structural engineer has been delegated responsibility for a portion of this project his or her signature is also required.
I have reviewed the approved construction documents for this project and all tests and special inspections required by Code are marked as “required” on this form.
FOR HCAI USE
Facility Name:
Arrowhead Regional Medical Center
Architect/Engineer of Record (Print Name)
Structural Engineer of Record (Print Name)
Project #:
S250159-36-00
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-H1OSH-FD-303A (R04.36)
03.20.2025Jeremy C. Welton
Tina W. Go 3-20-25
6/26/2025, 1:30:55 PM
Allen Cheng
SECTION I
Facility #:
17282
Architect/Engineer of Record (Print Name) Professional License # Architect/Engineer of Record (Signature) Date
Note: HCAI plan review staff must provide verification that the TIO program has been "Reviewed" prior to plan approval to confirm the applicability of the tests and inspections identified in the TIO program for work scope, building systems, and the construction materials shown in the design drawings. HCAI Field staff will issue subsequent "TIO Program Approval".
If "Approved with Comments" is checked the following comments shall be resolved by the designer prior to proceeding with the related construction:
TIO PROGRAM APPROVAL
Facility Name:
Arrowhead Regional Medical Center
FOR HCAI FIELD STAFF USE
NOTE: This Test, Inspection, and Observation Report shall be approved by HCAI field personnel prior to start of construction.
Samples of Test and Inspection Reports are NOT required for tests performed by laboratories approved through OPAA Program
This program is prepared and submitted for an OSHPD 1 project. OSHPD 1 projects include all construction and remodel projects for: general acute care hospitals, acute psychiatric hospitals, and general acute care hospitals providing only acute medical rehabilitation center services
(2022 CBC 1224.1).
Verified compliance reports shall be signed by the individual who performed the special inspection(s) as outlined in CAC 7-151 (c).
All reports shall clearly state whether the tests or special inspections were performed in accordance with the HCAI stamped approved documents and whether the results indicate compliance with those documents per CAC 7-149 (a). All IORs performing special inspections shall hold the appropriate certification and equipment, and shall obtain approval from the design professional of record and HCAI prior to performing such work.
Project #:
S250159-36-00
TIO Program Approved by HCAI Field Staff:
All test and special inspection reports shall be submitted to the IOR, hospital owner, architect in responsible charge, and the structural engineer by the responsible approved agency and/or individual per CAC 7-149(a). The responisble approved agency and/or individual shall be employed by the health facility, owner, or governing board or authority per CAC 7-149(b).
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-I1OSH-FD-303A (R04.36)
Tina W. Go C28335 3-20-25
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
TESTS
S a m p le s o f T e s p e c ti o n
R e p o lu d e d
O P
A A
N o a p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Individual)
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
STRUCTURAL TESTS
x12 Concrete
B -C
X
Concrete
CBC 1705A.3, 1903A.6 & 1910A.1; ACI 318 1.9.1 &
26.4.1.1
Cementitious materials
TBD
B -C
X Concrete
CBC 1705A.3, 1903A.5; ACI 318 1.9.1 & 26.4.1.2
Aggregates/Reactive aggregates
TBD
B -C
X Concrete
CBC 1705A.3; ACI 318 26.4.1.4; ASTM C1602
Water
TBD
B -C
X Concrete
CBC 1705A.3 & 1905A.1.17; ACI 318 26.12
Strength test
TBD
B -C
X
Concrete
CBC 1705A.3 & 1910A.2; ACI 318 20.2, 25.4.5.1 &
26.6.1.2
Metal reinforcement (including welded wire fabric and headed rebar)
TBD
B -C
X
Post-installed anchors
CBC 1910A.5
Installation verification test (includes adhesive, shot pins and mechanical anchors)
TBD
x14 Steel
B -S
X
Steel
CBC Table 1705A.2.1 & 2202A.1
Testing of unidentified steel or identification test for structural steel and cold formed steel
TBD
ELECTRICAL TESTS
B -E
X Insulation Testing
CEC 110.7
TBD
B -E
X Torque Electrical Connections
CEC 110.3(B) & 110.14(D)
TBD
PLUMBING TESTS
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.2.1 thru 5.1.12.2.7
Installer performed tests
TBD
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.2.6.7 & 5.1.12.2.7.6
Witness of 24-hour standing pressure test
TBD
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.3.1.1 thru 5.1.12.3.1.5
System inspection prior to concealment/cover
TBD
B -P
X Medical Gas and Vacuum
NFPA 99-2021 § 5.1.12.3.2.1
Inspection
TBD
Stage 1: Sequence 1 Select with "X" or provide required OPAA information:
SECTION B
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-B1 Stage 1OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
TESTS
S a m p le s o f T e s p e c ti o n
R e p o lu d e d
O P
A A
N o a p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Individual)
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
Stage 2: Sequence 3 Select with "X" or provide required OPAA information:
SECTION B
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
17282 S250159-36-00
B -P
X Existing Sewers and Drains
CPC 102.4.1, 105.3, & 712.0
Tested for conformance with requirements for new work
TBD
FIRE PROTECTION AND LIFE SAFETY SYSTEMS
B -F
P
X Fire Alarm
CFC 901.5 & CFC 907.7 NFPA 72-2022 §14.4
Acceptance and reacceptance testing
TBD
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-B2 Stage 2OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
ON-SITE SPECIAL
INSPECTIONS
S a m p le s o f T e s p e c ti o n
R e p o lu d e d
O P
A A
N o a p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Special Inspector)
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
STRUCTURAL SPECIAL INSPECTIONS
x12 Concrete
C -C
X Concrete
CBC 1705A.3; ACI-318 26.5.2 & 26.13
Placement of concrete
TBD
C -C
X Concrete
CBC 1705A.3; ACI-318 26.4.1.5
Admixtures
TBD
C -C
X Concrete
CBC 1705A.3; ACI-318 26.4
Mix design
TBD
C -C
X Concrete
CBC 1705A.3; ACI-318 26.13
Reinforcing steel & prestressing steel
TBD
C -C
X Concrete
CBC 1705A.3
CIP & post-installed anchors
TBD
x14 Steel
C -S
X Steel
CBC 1705A.2.5
Field welding
TBD
C -S
X Steel
AWS D1.1 3 & 4 & AWS D1.8 6.1
Field welding - WPS / WPQR
TBD
x18Nonstructural components, supports and attachments
C -N
X Plumbing, mechanical and electrical components
CBC 1705A.13.6
Anchorage, bracing, and vibration isolators
TBD
Stage 2: Sequence 3 Select with "X" or provide required OPAA information:
SECTION C
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-C1 Stage 2OSH-FD-303A (R04.36)
Facility Name:
Arrowhead Regional Medical Center
In d e x
S ta g e
R e q u ir e d
(S e le c t w it h
X
OFF-SITE SPECIAL
INSPECTIONS
S a m p le s o f T e s p e c ti o n
R e p o lu d e d
O P
A A
N o a p ir a ti o n
D a te
Responsible Approved Agency
And/Or Individual
(Identify Special Inspector)
C o m p li a n ri fi c a ti o n b y
I O
R
(I n it ia l/ D a te
H C
A I/
F D
D U s e
(I n it ia l/ D a te
STRUCTURAL SPECIAL INSPECTIONS
x11 Concrete
D -C
X Concrete
CBC 1705A.3; ACI-318 26.4
Mix design
TBD
D -C
X Concrete
CBC 1705A.3.3
Batch plant inspection
TBD
Stage 1: Sequence 1 Select with "X" or provide required OPAA information:
SECTION D
NOTE: Approved agencies, individuals, and all changes to the TIO program shall be identified, evaluated by the DPOR and approved by HCAI prior to proceeding with the related work.
Facility #: Project #:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-D1 Stage 1OSH-FD-303A (R04.36)
Facility #:
17282
REVISION
NUMBER
SYNOPSIS OF CHANGE
Architect/Engineer of
Record Signature
(Initial/date)
Structural Engineer of
Record Signature
(Initial/date)
DATE of Effective
Change
TESTING, INSPECTION, AND OBSERVATION PROGRAM NON-MATERIALLY ALTERING CHANGES
BY THE ARCHITECT OF RECORD / ENGINEER OF RECORD IN RESPONSIBLE CHARGE
SECTION J
Facility Name:
Arrowhead Regional Medical Center
HCAI FDD
CONCURRENCE
(Initial/date)
A signature below indicates that the DPOR has verified the acceptance statements in Section I of this Form are applicable to any approved agencies/testing laboratories and special inspectors added.
SUMMARY OF CHANGES TO THE TIO PROGRAM
NOTE: Note all changes shall be approved as amended construction documents per CAC 7-
153, or “concurred with” as non-material alterations per CAC 7-153(b), by HCAI prior to proceeding with the related work.
Project #:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY S-J1OSH-FD-303A (R04.36)
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