Lake Nona MedGas Example.pdf

Project:

Attention:

Completed By:

Annual Medical Gas Certification - CLC

Orlando VA Medical Center - Lake Nona

Frank D'Arpa - Medical Gas Certifier - N.I.T.C. #

12313456

THESE DOCUMENTS CONTAIN THE CERTIFICATION REPORTS FOR:

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

02/25/23

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

Fax: (866) 348-9650 1 of 25 Pages

(NFPA 99, 2018 Edition)

Section Results

1 Certificate of Compliance Permanent

2 Medical Air Source Data Tested

3 Medical Vacuum Source Data Tested

4 Manifold Source Data Tested

5 Master Alarm Data Tested

6 Area Alarm Data / Zone Valve Inspection / Tested

Medical Gas Outlets / Filter Analysis

7 Summary Included

CERTIFICATION REPORTS, DATA & FINDINGS

Table of Contents for:

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

Fax: (866) 348-9650

2 of 25 Pages

This certificate is issued - 02/25/23 by Mercury Medical®.

This certificate relates to the work performed pursuant to a request for testing services by -

Orlando VA Medical Center - Lake Nona CLC

In accordance with the terms of that agreement, Mercury Medical® has tested the medical gas piping system of said hospital or a specific area of said - Orlando VA Medical Center - Lake Nona CLC located in - Orlando, FL

And, hereby certifies that as of the time said inspection was performed and except as noted on the data sheets and non compliance-page.

(NFPA 99, 2018 Edition)

1 There are no cross connections found within the medical gas system as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

2 The medical gas alarm systems are functioning within the established limits as required by

NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

3 All valves have been tested for operation and leakage as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

4 All valves, gas outlets and alarms were properly labeled as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

5 Each positive pressure piping system has been purged, analyzed and the piping purity tested as defined by applicable standards as required by NFPA 99, Chapter 5 - Gas and Vacuum Systems.

6 Each positive pressure piping system has been purged, analyzed and the gas dispensed is of proper concentration as required by NFPA 99, Chapter 5 - Gas and Vacuum Systems.

7 Piping systems operations pressure/flows have been tested as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

8 All positive pressure gas systems used for patient application have been tested for particulate contamination as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

9 Medical vacuum outlets were tested as required by NFPA 99, 2018 Edition, Chapter 5 -

Gas and Vacuum Systems.

10 Source equipment was tested in accordance with NFPA 99, 2018 Edition, Chapter 5 -

Gas and Vacuum Systems.

The data sheets accompanying this certificate and final report form, substantiate the certification and provide additional information; they should therefore, be read carefully by all parties. Only those outlets in that portion of the system listed on the attached sheets are included within this certificate.

This certificate shall be rendered void at any time adjustments, modifications or maintenance is performed on the aforementioned systems and/or equipment after this date.

Frank D'Arpa

CERTIFICATE OF COMPLIANCE

Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

3 of 25 Pages

Section 2

Facility Name: Orlando VA Medical Center - Lake Nona CLC

Address:

Orlando, FL 32827

Project Name: Annual Medical Gas Certification Test Date: 02/25/23

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for Medical Air Compressor Source

Enclosure/Location: Mechanical Room

Package Model # : MTD0303445 Serial #: 4816888-651

Type: Oil Less RPM: 1760

HP: 3 Voltage: 460 FLA: 4.4

Motor Current 1 #1 Leg 4.4 #2 Leg 14 #3 Leg 14

Motor Current 2 #1 Leg 4.3 #2 Leg 14 #3 Leg 13.9

Total Compressors in Package: 2 # Operational: 18

Main Line Pressure is: 50 Capacity: 10.1 SCFM Each

Lead Pressure Switch Cut in: 80 Cut Out: 100

Lag Pressure Switch Cut in: 70 Cut Out: 90

Actual Wired to

Monitors Mfr. Serial # Reading Master

Dewpoint Powerex 0643 -40°F Yes

CO ENMET 1401 O PPM Yes

Filters (Pre) Powerex No

Filters (Post) Powerex No

Dryer 1 Powerex 0008 No

Dryer 2 Powerex 0008 No

Filter Analysis 0 CO2 PPM <25

Comments: Needs new auto drain on tank. Need float drains on condensate canisters

Recommendations:

Discrepancy:

MEDICAL AIR COMPRESSOR SOURCE DATA

13800 Veterans Way

Model #

PDPM1001

Co-Guard

PMD10T00AJ

PMD10T00AJ

Hydro Carbon PPM

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

4 of 25 Pages

Section 3

Address:

Project Name: Annual Medical Gas Certification

Test Date:

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for Vacuum Primary & Backup Source

Enclosure/Location: Mechanical Area

Package Model # : VTD030341 Serial #: 4816888-686

Type: Rotary RPM: 1725

HP: 3-Jan Voltage: 460 FLA: 3.9 SF: 1.115

Motor Current 1 #1 Leg 3.9 #2 Leg #3 Leg

Motor Current 2 #1 Leg 3.9 #2 Leg #3 Leg

Comments:

Recommendations:

Discrepancy:

VACUUM SOURCE DATA

13800 Veterans Way

Orlando, FL 32827

02/09/2021

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

5 of 25 Pages

Section 4

Address:

Orlando, FL 32827

Project Name: Annual Medical Gas Certification - CLC Test Date: 02/25/23

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for Oxygen Primary & Secondary Supply

Enclosure/Location: Manifold room

Manifold Manufacturer is: TRI-TECH

Model #: LLU12OX1L Serial #: 2011022-E-A

Liquid /Gas: Liquid

2 Right Bank: 2

Main Line Manifold Pressure: 55 PSI

Manifold Right Bank Pressure: 285 PSI

Manifold Left Bank Pressure: 196 PSI

Comments: 8 cylinder high pressure back up system

Recommendations:

Discrepancy:

OXYGEN MANIFOLD SOURCE DATA

13800 Veterans Way

Cylinders in Left Bank:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 6 of 25 Pages

Section 5

MASTER ALARM DATA

Facility Name: Orlando VA Medical Center - Lake Nona CLC

Address:

Project Name: Annual Medical Gas Certification Test Date: 02/25/23

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Setpoint

YES NO YES NO

X 40 X

X 40 X

X 12 X

X 60 X

X 60 X

X N/A X

N/A

N/A

N/A

N/A

N/A

Local Visual Local Audible Local Alarm Only

Yes Yes

Yes Yes

Yes Yes

Yes Yes

Local Visual Local Audible Local Alarm Only

Yes Yes

Comments:

Recommendations: Evaluate and repair signals/retest

Discrepancy: Master alarm signals not functioning properly for oxygen system.

13800 Veterans Way

Orlando, FL 32827

Manufacturer: Amico

Enclosure Location: B Unit Nurses

Station

Gas Labeled Functioning

Line Pressure Low Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum

Other

EVAC

Other

Line Pressure High Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Bulk Oxygen Site Switch Setpoint Wired To Master Not Wired To Master

Manifolds Secondary Supply In Use Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Other

Primary Liquid Level Low Yes

Secondary Supply In Use Yes

Medical Air Compressor Wired To Master Not Wired To Master

Dew Point High ( 39F@50psig)

Secondary Liquid Level Low Yes

Secondary Low Head Pressure Yes

Yes

Carbon Monoxide High (<10ppm) Yes

Compressor High Air Temp (Note14) Yes

Lag Compressor Running Yes

Air Receiver High Water (Note15)

Liquid Ring Comp High Water (Note16)

Vacuum Pumps Wired To Master Not Wired To Master

High Temp Yes

Lag Pump Running Yes

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 7 of 25 Pages

Section 6

Floor: Facility Name:

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum

EVAC

Other

O U T L E T S

□ Critical Area (Alarm Required)

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

N - Nitrogen

Yes x Non-Critical Area

Outside 1A207 Dental 1A207 □ (If applicable) Manufacturer/Model -

Alarm Location:

x Area alarm data alarm N/A

Zone Valve Location:

Areas Served

E - EVAC (WAGD)

Medical Air

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

10 - Leaking outlet

20 - Failed Flow Rate Test

30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

2 - Nitrous Oxide

O xy ge n

S C

F M

3.

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a rb on

D io xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room No.

1 P1A207 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = psig Vacuum = psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Lab Air = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Attached Outlet Data sheet for this zone.

Actual Static

Pressure

H a lo g e n a te d h y d ro c a rb o n s p p m

D e w P o in t

F

Actual Static

PressureGas

DISS AmicoAmico

Gas

P a rt ic u la te m g n o n -M e th a n e

H d ro c a rb o n s p p m

*P/F = Pass/Fail

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 8 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

50 - Unable to test (in use)

60 - Missing parts

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air x Non-Critical Area

B Unit Spring Hill Village - B Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room No.

1 P 1 P 1 P1B012 Good

1 P 1 P 1 P1B014 Good

1 P 1 P 1 P1B016 Good

1 P 1 P 1 P1B018 Good

1 P 1 P 1 P1B020 Good

1 P 1 P 1 P1B022 Good

1 P 1 P 1 P1B024 Good

1 P 1 P 1 P1B027 Good

1 P 1 P 1 P Good1B029

1 P 1 P 1 P1B030 Good

1 P 1 P 1 P1B032 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Attached Outlet Data sheet for this zone.

Amico Amico DISS

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 9 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

Orlando, FL 32827 02/25/23

13800 Veterans Way

B Unit Spring Hill Village - B Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom Number

Notes

1 P 1 P 1 P1B034 Good

1 P 1 P 1 P1B036 Good

1 P 1 P 1 P1B038 Good

1 P 1 P 1 P1B040 Good

*P/F = Pass/Fail

Comments:

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 10 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 48 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23 x Non-Critical Area

C Unit Spring Hill Village - C Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Notes

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

1 P 1 P 1 P

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

Style

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations: Repair replace oxygen sensor

Discrepancy: Area alarm Oxygen sensor not accurate

Room No.

1C006 Good

1C008 Good

1C010 Good

1C012 Good

1C014 Good

1C016 Good

1C018 Good

1C020 Good

1C022 Good

1C024 Good

1C026 Good

Oultlets Manufacturer

Amico Amico DISS n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Attached Outlet Data sheet for this zone.

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 11 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

02/25/23

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

C Unit Spring Hill Village - C Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room Number

1 P 1 P 1 P1C028 Good

1 P 1 P 1 P1C027 Good

1 P 1 P 1 P1C029 Good

1 P 1 P 1 P1C032 Good

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 12 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23 x Non-Critical Area

D Unit Spring Hill Village - D Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.

Notes

1 P 1 P 1 P1D012 Good

1 P 1 P 1 P1D014 Good

1 P 1 P 1 P1D016 Good

1 P 1 P 1 P1D018 Good

1 P 1 P 1 P1D020 Good

1 P 1 P 1 P1D022 Good

1 P 1 P 1 P1D024 Good

1 P 1 P 1 P1D029 Good

1 P 1 P 1 P1D027 Good

1 P 1 P 1 P1D030 Good

1 P 1 P 1 P1D032 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations: Repair / Replace

Discrepancy: Alarm is off

Amico Amico DISS n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Attached Outlet Data sheet for this zone.

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 13 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

02/25/23

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

D Unit Spring Hill Village - D Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room Number

1 P 1 P 1 P1D034 Good

1 P 1 P 1 P1D036 Good

1 P 1 P 1 P1D038 Good

1 P 1 P 1 P1D040 Good

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 14 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23 x Non-Critical Area

E Unit Spring Hill Village - E Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.

Notes

1 P 1 P 1 P1E004 Good

1 P 1 P 1 P1E006 Good

1 P 1 P 1 P1E008 Good

1 P 1 P 1 P1E010 Good

1 P 1 P 1 P1E012 Good

1 P 1 P 1 P1E014 Good

1 P 1 P 1 P1E016 Good

1 P 1 P 1 P1E018 Good

1 P 1 P 1 P1E020 Good

1 P 1 P 1 P1E022 Good

1 P 1 P 1 P1E024 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Amico Amico DISS n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Attached Outlet Data sheet for this zone.

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 15 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

02/25/23

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

E Unit Spring Hill Village - E Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room Number

1 P 1 P 1 P1E026 Good

1 P 1 P 1 P1E025 Good

1 P 1 P 1 P1E027 Good

1 P 1 P 1 P1E032 Good

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 16 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23 x Non-Critical Area

F Unit Oak Tree Village - F Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.

Notes

1 P 1 P 1 P1F012 Good

1 P 1 P 1 P1F014 Good

1 P 1 P 1 P1F016 Good

1 P 1 P 1 P1F018 Good

1 P 1 P 1 P1F020 Good

1 P 1 P 1 P1F022 Good

1 P 1 P 1 P1F024 Good

1 P 1 P 1 P1F027 Good

1 P 1 P 1 P1F029 Good

1 P 1 P 1 P1F030 Good

1 P 1 P 1 P1F032 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Amico Amico DISS n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Attached Outlet Data sheet for this zone.

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 17 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

02/25/23

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

F Unit Oak Tree Village - F Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room Number

1 P 1 P 1 P1F034 Good

1 P 1 P 1 P1F036 Good

1 P 1 P 1 P1F038 Good

1 P 1 P 1 P1F040 Good

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 18 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23 x Non-Critical Area

G Unit Oak Tree Village - G Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.

Notes

1 P 1 P 1 P1G006 Good

1 P 1 P 1 P1G008 Good

1 P 1 P 1 P1G010 Good

1 P 1 P 1 P1G012 Good

1 P 1 P 1 P1G014 Good

1 P 1 P 1 P1G016 Good

1 P 1 P 1 P1G018 Good

1 P 1 P 1 P1G020 Good

1 P 1 P 1 P1G022 Good

1 P 1 P 1 P1G024 Good

1 P 1 P 1 P1G026 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Amico Amico DISS n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Attached Outlet Data sheet for this zone.

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 19 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

02/25/23

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

G Unit Oak Tree Village - G Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room Number

1 P 1 P 1 P1G027 Good

1 P 1 P 1 P1G028 Good

1 P 1 P 1 P1G029 Good

1 P 1 P 1 P1G032 Good

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 20 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23 x Non-Critical Area

H Unit Blue Water Village - H Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.

Notes

1 P 1 P 1 P1H012 Good

1 P 1 P 1 P1H014 Good

1 P 1 P 1 P1H016 Good

1 P 1 P 1 P1H018 Good

1 P 1 P 1 P1H020 Good

1 P 1 P 1 P1H022 Good

1 P 1 P 1 P1H024 Good

1 P 1 P 1 P1H026 Good

1 P 1 P 1 P1H028 Good

1 P 1 P 1 P1H030 Good

1 P 1 P 1 P1H032 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Amico Amico DISS n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Attached Outlet Data sheet for this zone.

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 21 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

02/25/23

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

H Unit Blue Water Village - H Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room Number

1 P 1 P 1 P1H033 Good

1 P 1 P 1 P1H034 Good

1 P 1 P 1 P1H035 Good

1 P 1 P 1 P1H042 Good

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 22 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

53 Yes 53 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 24 Yes 24 12 N/A X

EVAC

Other

O U T L E T S

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827 02/25/23 x Non-Critical Area

J Unit Blue Water Village - J Unit x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Nurses station □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served □ Critical Area (Alarm Required)

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

50 - Unable to test (in use)

60 - Missing parts

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.

Notes

1 P 1 P 1 P1J004 Good

1 P 1 P 1 P1J006 Good

1 P 1 P 1 P1J008 Good

1 P 1 P 1 P1J010 Good

1 P 1 P 1 P1J012 Good

1 P 1 P 1 P1J014 Good

1 P 1 P 1 P1J016 Good

1 P 1 P 1 P1J020 Good

1 P 1 P 1 P1J021 Good

1 P 1 P 1 P1J022 Good

1 P 1 P 1 P1J023 Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 55 psig 99% Carbon Dioxide = psig

21% Medical Air = 53 psig Vacuum = 24 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Amico Amico DISS n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Attached Outlet Data sheet for this zone.

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 23 of 25 Pages

1st Address:

Building: Test Date:

CLC Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

O U T L E T S

02/25/23

OUTLETS DATA SHEET ATTACHMENT

Orlando VA Medical Center - Lake Nona CLC

13800 Veterans Way

Orlando, FL 32827

J Unit Blue Water Village - J Unit

Alarm Location

Nurses Station

Zone Valve Location

Areas Served O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C ar bo n

D io xi de

S C

V ac uu m

S C

W A G

D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room Number

1 P 1 P 1 P1J024 Good

1 P 1 P 1 P1J026 Good

1 P 1 P 1 P1J028 Good

1 P 1 P 1 P1J030 Good

Recommendations:

Discrepancy:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 24 of 25 Pages

Section 7

Address:

Orlando, FL 32827

Project Name: Annual Medical Gas Certification Test Date: 02/25/23

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Summary

Recom-

SECTION # Comments mendations Discrepancies

2 Medical Air Source -- -- see page(s) : 4

3 Medical Vacuum Source -- see page(s) :

4 Manifold Source -- see page(s) :

7 7

5 Master Alarms -- see page(s) :

11,13 11,13

6 Area Alarms / Zone Valves / -- see page(s) :

Medical Gas Outlets/Filter

Analyis

CERTIFICATION DISCREPANCY SUMMARY

13800 Veterans Way

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 25 of 25 Pages

Project:

Attention:

Completed By:

Annual Medical Gas Certification

Orlando VA Medical Center - Lake Nona

Frank D'Arpa - Medical Gas Certifier - N.I.T.C. #

12313456

THESE DOCUMENTS CONTAIN THE CERTIFICATION REPORTS FOR:

Orlando VA Medical Center - Lake Nona

13800 Veterans Way

Orlando, FL 32827

02/25/2023

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 1 of 83 Pages

(NFPA 99, 2018 Edition)

Section Results

1 Certificate of Compliance Permanent

2 Medical Air Source Data Tested

3 Medical Vacuum Source Data Tested

4 Manifold Source Data Tested

5 Master Alarm Data Tested

6 Area Alarm Data / Zone Valve Inspection / Tested

Medical Gas Outlets / Filter Analysis

7 Summary Included

CERTIFICATION REPORTS, DATA & FINDINGS

Table of Contents for:

Orlando VA Medical Center - Lake Nona

13800 Veterans Way

Orlando, FL 32827

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

2 of 83 Pages

This certificate is issued - 02/25/2023 by Mercury Medical®.

This certificate relates to the work performed pursuant to a request for testing services by -

Orlando VA Medical Center - Lake Nona

In accordance with the terms of that agreement, Mercury Medical® has tested the medical gas piping system of said hospital or a specific area of said - Orlando VA Medical Center - Lake Nona located in - Orlando, FL

And, hereby certifies that as of the time said inspection was performed and except as noted on the data sheets and non compliance-page.

(NFPA 99, 2018 Edition)

1 There are no cross connections found within the medical gas system as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

2 The medical gas alarm systems are functioning within the established limits as required by

NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

3 All valves have been tested for operation and leakage as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

4 All valves, gas outlets and alarms were properly labeled as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

5 Each positive pressure piping system has been purged, analyzed and the piping purity tested as defined by applicable standards as required by NFPA 99, Chapter 5 - Gas and Vacuum Systems.

6 Each positive pressure piping system has been purged, analyzed and the gas dispensed is of proper concentration as required by NFPA 99, Chapter 5 - Gas and Vacuum Systems.

7 Piping systems operations pressure/flows have been tested as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

8 All positive pressure gas systems used for patient application have been tested for particulate contamination as required by NFPA 99, 2018 Edition, Chapter 5 - Gas and Vacuum Systems.

9 Medical vacuum outlets were tested as required by NFPA 99, 2018 Edition, Chapter 5 -

Gas and Vacuum Systems.

10 Source equipment was tested in accordance with NFPA 99, 2018 Edition, Chapter 5 -

Gas and Vacuum Systems.

The data sheets accompanying this certificate and final report form, substantiate the certification and provide additional information; they should therefore, be read carefully by all parties. Only those outlets in that portion of the system listed on the attached sheets are included within this certificate.

This certificate shall be rendered void at any time adjustments, modifications or maintenance is performed on the aforementioned systems and/or equipment after this date.

Frank D'Arpa

CERTIFICATE OF COMPLIANCE

Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

3 of 83 Pages

Section 2

Facility Name: Orlando VA Medical Center - Lake Nona

Address:

Project Name: Annual Medical Gas Certification

Test Date:

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

This data is for BULK OXYGEN Primary Supply

Enclosure/Location: Bulk Oxygen Pad

Bulk Supplier: Air Liquide

Main Tank Pressure Setting: 120 PSI Reserve Liquid

Low Setting -

100 PSI 30

Reserve Type Liquid/Gas: Gas Reserve Size: 1500

OR # of "H" Bottles:

Main Liquid Level Low Setting: 35

Emergency Fill Box: X Secured: X

Yes No Yes No

Main Tank

Mfr./Date: Model #: 6000 Gal SN: 26247

Reserve Tank

Mfr./Date: Model #: 1500 Gal SN: 26352

Delivery Pressure: 50 PSI

Comments:

Recommendations:

Discrepancy:

BULK OXYGEN SITE DATA

13800 Veterans Way

Orlando, FL 32827

02/25/2023

Reserve Pressure:

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

Fax: (866) 348-9650

4 of 83 Pages

Bulk Oxygen

Site Data

Section 3

Address:

Orlando, FL 32827

Project Name: Annual Medical Gas Certification Test Date: 02/25/2023

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

This data is for MEDICAL AIR COMPRESSOR Source

Enclosure/Location: Mechanical Room

Package Model # : MSH150655183181 Serial #: 3/15/20012 5183181-925

Type: Scroll RPM: 1725

HP: 15 Voltage: 480 FLA: 14.1

Motor Current 1 #1 Leg 13.9 #2 Leg 14 #3 Leg 14

Motor Current 2 #1 Leg 13.9 #2 Leg 14 #3 Leg 13.9

Total Compressors in Package: 18 # Operational: 18

Main Line Pressure is: 52 Capacity: N/A SCFM Each

Lead Pressure Switch Cut in: 80 Cut Out: 100

Lag Pressure Switch Cut in: 70 Cut Out: 90

Actual Wired to

Monitors Mfr. Serial # Reading Master

Dewpoint Powerex N/A -61° Yes

CO ENMET Yes

Filters (Pre) YES No

Filters (Post) YES No

Dryer 1 YES No

Dryer 2 YES No

Filter Analysis <25 CO2 PPM <1

Recommendations:

Discrepancy:

MEDICAL AIR COMPRESSOR SOURCE DATA

13800 Veterans Way

Model #

PDPM1001

Hydro Carbon PPM

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

5 of 83 Pages

Address:

Project Name: Annual Medical Gas Certification

Test Date:

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for VACUUM Primary & Backup Source

Enclosure/Location: Mechanical Room

Package Model # : CUPT15055122708 Serial #: 1/30/2012 5122708-687

Type: Claw RPM: 1725

HP: 15 Voltage: 460 FLA: 14.1 SF: 1.15

Motor Current 1 #1 Leg 14 #2 Leg 14 #3 Leg 14.1

Motor Current 2 #1 Leg 14 #2 Leg 14 #3 Leg 13.9

Motor Current 3 #1 Leg 13.9 #2 Leg 14 #3 Leg 14

Total Vac Pumps in Package: 3 # Operational: 2

Source Line Vacuum is: 23 " Hg Capacity: N/A SCFM Each

Lead Pressure Switch Cut in: 18 Cut Out: 23

Lag Pressure Switch Cut in: 12 Cut Out: 21

Comments:

Recommendations: Repair / Replace/Evaluate

Discrepancy: 1 out of 3 vacuum pumps functioning

VACUUM SOURCE DATA

13800 Veterans Way

Orlando, FL 32827

02/25/23

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

6 of 83 Pages

Address:

Project Name: Annual Medical Gas Certification

Test Date:

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for VACUUM Primary & Backup Source

Enclosure/Location: Mechanical Room

Package Model # : CUPT15055122708 Serial #: 1/30/2012 5122708-704

Type: Oil-less RPM: 1725

HP: 5 Voltage: 460 FLA: 14 SF: 1.15

Starter Mfr: Schneider Heater Size: LC1D18 Fuse Size: 1-1/4

Motor Current 1 #1 Leg 6.1 #2 Leg 6.0 #3 Leg 14.1

Motor Current 2 #1 Leg 6.1 #2 Leg 6.0 #3 Leg 13.9

Total Vac Pumps in Package: 2 # Operational: 1

Source Line Vacuum is: 20 " Hg Capacity: N/A SCFM Each

Lead Pressure Switch Cut in: 20 Cut Out: 25

Lag Pressure Switch Cut in: 18 Cut Out: 23

Comments:

Recommendations:

Discrepancy:

WAGD SOURCE DATA

13800 Veterans Way

Orlando, FL 32827

02/25/23

11300 49th Str. No.

Clearwater, FL 33762

Ph: (800) 990-6372

7 of 83 Pages

Address:

Orlando, FL 32827

Project Name: Annual Medical Gas Certification Test Date: 02/25/2023

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for NITROGEN Primary & Secondary Supply

Enclosure/Location: Manifold room

Manifold Manufacturer is: Amico

Model #: M2HD-D-HH-U-NIT Serial #: 2011022-E-A

Liquid /Gas: Gas

12 Right Bank: 12

Main Line Manifold Pressure: 167 PSI

Manifold Right Bank Pressure: 400 PSI

Manifold Left Bank Pressure: 2239 PSI

Comments:

Recommendations:

Discrepancy:

NITROGEN MANIFOLD SOURCE DATA

13800 Veterans Way

Cylinders in Left Bank:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 8 of 83 Pages

Address:

Orlando, FL 32827

Project Name: Annual Medical Gas Certification Test Date: 02/25/2023

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for CARBON DIOXIDE Primary & Secondary Supply

Enclosure/Location: Manifold room

Manifold Manufacturer is: Amico

Model #: M3A-DL-HHH-U-CO2 Serial #: 20210913-0003

Liquid /Gas: Gas

4 Right Bank: 4

Main Line Manifold Pressure: 52 PSI

Manifold Right Bank Pressure: 200 PSI

Manifold Left Bank Pressure: 200 PSI

Comments:

Recommendations:

Discrepancy:

CARBON DIOXIDE MANIFOLD SOURCE DATA

13800 Veterans Way

Cylinders in Left Bank:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 9 of 83 Pages

Address:

Orlando, FL 32827

Project Name: Annual Medical Gas Certification Test Date: 02/25/2023

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for NITROUS OXIDE Primary & Secondary Supply

Enclosure/Location: Manifold room

Manifold Manufacturer is: Amico

Model #: M2HD-D-HH-U-N2O Serial #: 20101208-C-A

Liquid /Gas: Gas

6 Right Bank: 6

Main Line Manifold Pressure: 51 PSI

Manifold Right Bank Pressure: 260 PSI

Manifold Left Bank Pressure: 300 PSI

Comments:

Recommendations:

Discrepancy:

NITROUS OXIDE MANIFOLD SOURCE DATA

13800 Veterans Way

Cylinders in Left Bank:

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 10 of 83 Pages

Facility Name: Orlando VA Medical Center - Lake Nona

Address:

Project Name: Annual Medical Gas Certification Test Date: 02/25/2023

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Setpoint

YES NO YES NO

x 40 x x 40 x x 40 x x 135 x x 40 x x 12 x x 12 x x 60 x x 60 x x 60 x x 195 x x 60 x

N/A

N/A x N/A x x N/A x x N/A x

N/A

Local Visual Local Audible Local Alarm Only x x x x x x x x

Local Visual Local Audible Local Alarm Only x x x x

Comments: Dental Air in lag

Recommendations:

Discrepancy:

13800 Veterans Way

Orlando, FL 32827

Manufacturer: Amico Alert II

Enclosure Location: Biomed 1st Floor Gas Labeled Functioning

Line Pressure Low Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum

Other

EVAC

Other

Line Pressure High Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Bulk Oxygen Site Switch Setpoint Wired To Master Not Wired To Master

Manifolds Secondary Supply In Use Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Other

Primary Liquid Level Low Yes

Secondary Supply In Use Yes

Medical Air Compressor Wired To Master Not Wired To Master

Dew Point High ( 39F@50psig)

Secondary Liquid Level Low Yes

Secondary Low Head Pressure Yes

Yes

Carbon Monoxide High (<10ppm) Yes

Compressor High Air Temp (Note14) Yes

Lag Compressor Running Yes

Air Receiver High Water (Note15)

Liquid Ring Comp High Water (Note16)

Vacuum Pumps Wired To Master Not Wired To Master

High Temp Yes

Lag Pump Running Yes

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 11 of 83 Pages

Facility Name: Orlando VA Medical Center - Lake Nona

Address:

Project Name: Annual Medical Gas Certification Test Date: 02/25/2023

Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Setpoint

YES NO YES NO

x 40 x x 40 x x 40 x x 135 x x 40 x x 12 x x 12 x x 60 x x 60 x x 60 x x 195 x x 60 x

N/A

N/A

N/A x

N/A x

N/A x

N/A

Local Visual Local Audible Local Alarm Only x x x x x x x x

Local Visual Local Audible Local Alarm Only x x x x

Comments: Dental Air in lag

Recommendations:

Discrepancy:

Vacuum Pumps Wired To Master Not Wired To Master

High Temp Yes

Lag Pump Running Yes

Lag Compressor Running Yes

Air Receiver High Water (Note15)

Liquid Ring Comp High Water (Note16)

Medical Air Compressor Wired To Master Not Wired To Master

Dew Point High ( 39F@50psig)

Secondary Liquid Level Low Yes

Secondary Low Head Pressure Yes

Yes

Carbon Monoxide High (<10ppm) Yes

Compressor High Air Temp (Note14) Yes

Bulk Oxygen Site Switch Setpoint Wired To Master Not Wired To Master

Manifolds Secondary Supply In Use Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Other

Primary Liquid Level Low Yes

Secondary Supply In Use Yes

Other

EVAC

Other

Line Pressure High Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Line Pressure Low Oxygen

Medical Air

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum

13800 Veterans Way

Orlando, FL 32827

Manufacturer: Amico Alert II

Enclosure Location: Security 2nd Floor Gas Labeled Functioning

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 12 of 83 Pages

1st Address:

Building: Test Date:

Hospital Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 50 Yes

50 Yes

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 21 Yes

EVAC

Other 35 Yes

O U T L E T S

□ Critical Area (Alarm Required)

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona

13800 Veterans Way

Orlando, FL 32827 02/25/2023

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

N - Nitrogen

Yes

□ Non-Critical Area

Outside Biomed 1H107 □ (If applicable) Manufacturer/Model -

Alarm Location:

□ Area alarm data alarm N/A

Zone Valve Location:

Areas Served

E - EVAC (WAGD)

Medical Air Yes

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

10 - Leaking outlet

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

Yes 50 - Unable to test (in use)

60 - Missing parts

2 - Nitrous Oxide

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room No.

1 P 1 P 1 PStation 1 Good

1 P 1 P 1 PStation 2 Good

1 P 1 P 1 P GoodStation 3

1 P 1 P 1 P GoodStation 4

1 P 1 P 1 P GoodStation 5

1 P 1 P 1 P GoodStation 6

1 P 1 P 1 PStation 7 Good

1 P 1 P 1 P GoodStation 8

1 PLab Air

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 50 psig 99% Carbon Dioxide = psig

21% Medical Air = 50 psig Vacuum = 21 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Lab Air = 35 psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Attached Outlet Data sheet for this zone.

Actual Static

Pressure

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

Actual Static

PressureGas

DISS AmicoAmico

Gas

P a rt ic u la te m g n o n -M e th a d ro c a rb o n s p p m

*P/F = Pass/Fail

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 13 of 83 Pages

1st Address:

Building: Test Date:

Hospital Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 54 Yes 54 40 60 X

55 Yes 55 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 22 Yes 22 12 N/A X

EVAC

Other

O U T L E T S

50 - Unable to test (in use)

60 - Missing parts

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

□ Non-Critical Area

Outside Exam 9 1A705, 1A707, 1A709, 1A711

1A713, 1A715, 1A717, 1A721

1A109A, 1A109D x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Outside Exam 21 □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served x Critical Area (Alarm Required)

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona

13800 Veterans Way

Orlando, FL 32827 02/25/2023

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room No.

2 P 2 P 3 P1A705 Good

2 P 2 P 3 P1A707 Good

2 P 2 P 3 P1A709 Good

2 P 2 P 3 P1A711 Good

2 P 2 P 3 P1A713 Good

2 P 2 P 3 P1A715 Good

2 P 2 P 3 P1A717 Good

2 P 2 P 3 P Good1A721

2 P 2 P 3 P1A109A Good

2 P 2 P 3 P1A109D Good

NOTE: Oxygen and Medical Air outlets serving critical care areas will be tested at 6 SCFM for 3 seconds prior to the minimum requirements listed above

StyleOultlets Manufacturer

99% Oxygen = 54 psig 99% Carbon Dioxide = psig

21% Medical Air = 54 psig Vacuum = 23 psig

99% Nitrous Oxide = psig EVAC = psig

99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F

□ P P P P

Comments:

Recommendations:

Discrepancy:

Attached Outlet Data sheet for this zone.

Amico Amico DISS

*P/F = Pass/Fail

Gas

Actual Static

Pressure Gas

Actual Static

Pressure

P a rt ic u la te m g n o n -M e th a d ro c a rb o n s p p m

H a lo g e n a d ro c a rb o n s p p m

D e w P o in t

F

11300 49th Str. No.

Clearwater, FL 33762

Fax: (866) 348-9650 14 of 83 Pages

1st ER Address:

Building: Test Date:

Hospital Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456

Notes/Legend:

Setpoints | Functioning

PSIG

or Hg Low High Yes No

Oxygen 55 Yes 55 40 60 X

56 Yes 56 40 60 X

Nitrous Oxide

Nitrogen

Carbon Dioxide

Vacuum 22 Yes 22 12 N/A X

EVAC

Other

O U T L E T S

50 - Unable to test (in use)

60 - Missing parts

20 - Failed Flow Rate Test

Yes 30 - Failed Pressure Test

40 - Can't insert; won't lock

10 - Leaking outlet

Zone Gases Installed

Correctly

Gauges

Present

Alarm PSIG or Hg

V - Vacuum

C - Carbon Dioxide

Yes E - EVAC (WAGD)

Medical Air Yes N - Nitrogen

2 - Nitrous Oxide

ALARM DATA O - Oxygen

Zone Valve Value Data A - Medical Air

□ Non-Critical Area

Outside 1A-118 1A-118,1A-120,1A-122, 1A-116,1A-112

1A-109A, 1A-109C, 1A-110, 1A-108

1A-106,1A-104,1A-102, 1A-101 x (If applicable) Manufacturer/Model -

Alarm Location: AMICO

Outside Exam 21 □ Area alarm data alarm N/A

Zone Valve Location:

Areas Served x Critical Area (Alarm Required)

ZONE / ALARM / OUTLETS DATA SHEET

Orlando VA Medical Center - Lake Nona

13800 Veterans Way

Orlando, FL 32827 02/25/2023

O xy ge n

S C

M ed ic al

A ir

S C

N itr ou s

O xi de

S C

N itr og en

S C

C a xi de

S C

V ac u um

S C

W A

G D

S C

Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F

Notes

Room No.

2 P 2 P 3 P1A-118 Good

2 P 2 P 3 P1A-120 Good

2 P 2 P 3 P1A-122 Good

2 P 2 P 3 P1A-116 Good

2 P 2 P 3 P1A-112…