ARMC Central Plant Medical Vacuum System Replacement - HCAI TIO.pdf

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Attached to
10. 10. 1321 ARMC Central Plant Medical Vacuum System Replacement
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)

File details come from the government source that posted it. Updated .