Veira Medgas Example.pdf
PDF 2 MB Posted
- Attached to
- J043--FY25: OVAHCS Medical Gas Testing, Inspection, Certification and Preventative Maintenance.
- Solicitation number
- 36C24825Q0759
About this file
This document is a Medical Gas Certification report for the Viera VA Outpatient Clinic in Melbourne, Florida, conducted on January 26, 2023, by Mercury Medical. The comprehensive certification includes testing and inspection of multiple medical gas systems, including medical air compressors, vacuum pumps, oxygen and nitrous oxide manifolds, and medical gas outlets across various facility zones. The report covers critical areas such as zone valve data, alarm systems, outlet functionality, and pressure measurements for oxygen, medical air, nitrous oxide, and vacuum systems.
The certification was performed by Frank D'Arpa (Medical Gas Certifier, N.I.T.C. # 12313456) and follows NFPA 99, 2018 Edition standards. The testing examined multiple critical parameters including line pressures, gas concentrations, outlet performance, alarm functionality, and system integrity across different facility zones like recovery areas, endoscopy rooms, and nurses stations. The report indicates that most systems passed inspection, with some detailed notes on specific outlet and system performance, though no major discrepancies were explicitly highlighted in the summary section.
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Other files
| File | Type | Posted |
|---|---|---|
| S06 36C24825Q0759 0002.pdf | ||
| 36C24825Q0759 0002.docx | DOCX document | |
| S06 36C24825Q0759 0001.pdf | ||
| 36C24825Q0759 0001.docx | DOCX document | |
| S02 36C24825Q0759_final.pdf | ||
| D.5 ATTACHMENT D MEDGAS Equiptment Inventory_By Campus_w-images.xlsx | XLSX spreadsheet | |
| Lake Baldwin MedGas Example.pdf | ||
| Lake Nona MedGas Example.pdf |
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Text version
Site Contact Person Contact Title Phone #
EQUIPMENT pick one Air Compressor/System Vacuum Pump/System Other
Maintenance Interval - pick one Quarterly PM Semi-Annual PM Quarterly and Annual PM One-Time PM
Location in facility Temp in equipment room °F
Manufacturer Accessories
Model Number
Serial Number
Drawing, Job Number
Motor Plate Info: Amps SF Rated Voltage HP
Voltage Readings: Lead 1-2 Check here if single phase
Lead 1-3
Lead 2-3
Amperage Readings:
Lead 1
Lead 2
Lead 3
Visual Checks:
Rotation
Oil Level
Hours
Overloads set at
H-O-A Switch
Belt Tension
Pump Temp °F
Max Vac inches hg
Vane Width*
*applies to dry rotary vane pumps only
Pressure Switch Settings:
On
Off
Air Dryer/Air Treatment device info: Bank/Unit 1 Bank/Unit 2 Bank/Unit 1 Bank/Unit 2
Bank in service on arrival Suction pressure (if fitted)
Bank in service at completion (dryers switched) Filter element(s) condition
Tower changeover OK (desiccant dryers) Dew point °F
Other Operating Parameters:
Horn audible Pumps alternate correctly Oil / filter changed
Auto-drains functional Intake filters checked CO monitor operating
Panel lights functional Motor bearings lubed DP monitor operating
Bypass correctly set Gearcase oil level checked Lag alarm operating
Exhaust outlet screen checked for silncer debris (only applies to Rietschle and Busch dry claw vacuum pumps)
All screw terminals tightened in control panel; control panel checked for arcing
OWNER / OWNER'S REPRESENTATIVE DATE
CITY & STATE
CITY & STATE
WO #:
TECH:
Medical Technology Associates, Inc. Corporate Office: 6651 102nd Ave N, Pinellas Park, FL 33782 Tel 877-569-8886 Fax
727-548-8622 Form PM1 - 2015-06
Future service needs and/or service notes:
MTA SERVICE TECHNICIAN DATE
DATE
PO #
CUSTOMER
"" or "Y" = Yes or OK, "X" or "N" = No or Not OK, "-" or "N/A" = Not Applicable NOTE: All fields do not apply to all installations.
Lead Lag 1 Lag 2 Lag 3
FACILITY
PREVENTATIVE MAINTENANCE SERVICE REPORT
AIR COMPRESSOR - VACUUM PUMP
Pump 4Pump 3
Pump 1 Pump 2 Pump 3 Pump 4
Pump 1 Pump 2
NancyH Line
Maintenance Interval - pick one Quarterly PM Semi-Annual PM Quarterly and Annual PM One-Time PM Location in facility Temp in equipment room °F Manufacturer Accessories Model Number Serial Number Drawing, Job or Q Number
Motor Plate Info: Amps SF Rated Voltage HP
Voltage Readings: Lead 1-2 Check here if single phase Lead 1-3 Lead 2-3
Amperage Readings:
Lead 1 Lead 2 Lead 3
Amperage Readings:
Lead 1 Lead 2 Lead 3
Visual Checks: AC 1 AC 2 AC 3 AC 4 AC 5 AC 6 AC 7 AC 8 Rotation Hours Overloads set at H-O-A Switch Belt Tension Pump Temp °F
Pressure Switch Settings:
On Off
Pressure Switch Settings:
On Off
Time to Satisfy Pressure Switch (In Seconds)
Air Dryer/Air Treatment device info:
Pick one: Refrigerant Bank/Unit 1 Bank/Unit 2
Dessicant Bank/Unit 1 Bank/Unit 2 Suction pressure (if fitted) Bank in service on arrival Filter element(s) condition Bank in service at completion (dryers switched) Dew point °F indicated Tower changeover OK (desiccant dryers) Dew point °F actual
Other Operating Parameters:
Horn audible Pumps alternate correctly Auto-drains functional Intake filters checked Panel lights functional Motor bearings lubed Bypass correctly set Gearcase oil level checked
Oil / filter changed CO monitor operating DP monitor operating Lag alarm operating Control Cabinet Filter Clean Scroll Greased as Required
Touch screen functioning Tip seals due for scroll compessors 5000hrs HP and 10000 hrs for SP? __________ All screw terminals tightened in control panel; control panel checked for arcing _________
AC 1 AC 2
PREVENTATIVE MAINTENANCE SERVICE REPORT
AIR COMPRESSOR SYSTEM
AC 4
"" or "Y" = Yes or OK, "X" or "N" = No or Not OK, "-" or "N/A" = Not Applicable NOTE: All fields do not apply to all installations.
Lead
TECH:
Lag 3
FACILITY
AC 3
DATE
PO #
CUSTOMER
Medical Technology Associates, LLC Corporate Office: 6651 102nd Ave N, Pinellas Park FL 33782 Tel 877-569-8886 Fax 877-787-3220 Form PM1a2 - v2023-03
Future service needs and/or service notes:
MTA SERVICE TECHNICIAN DATE
Lag 1 Lag 2
CITY & STATE
CITY & STATE
WO #:
RESPONSIBLE FACILITY AUTHORITY DATE
AC 5 AC 6 AC 7 AC 8
Lag 4 Lag 5 Lag 6 Lag 7
AC 7 AC 8
AC 1 AC 2 AC 3 AC 4
AC 5 AC 6
PREVENTATIVE MAINTENANCE SERVICE REPORT
Amperage Readings:
Lead 1 Lead 2 Lead 3
Amperage Readings:
Lead 1 Lead 2 Lead 3
Visual Checks: AC 9 AC10 AC11 AC12 AC13 AC14 AC15 AC16 Rotation Hours Overloads set at H-O-A Switch Belt Tension Pump Temp °F
Pressure Switch Settings:
On Off
Pressure Switch Settings:
On Off
Time to Satisfy Pressure Switch (In Seconds)
AIR COMPRESSOR SYSTEM
AC 9 AC 10 AC 12
"" or "Y" = Yes or OK, "X" or "N" = No or Not OK, "-" or "N/A" = Not Applicable NOTE: All fields do not apply to all installations.
DATE
AC 9
TECH:
AC 12
FACILITY
AC 11
PO #
CUSTOMER
Medical Technology Associates, LLC Corporate Office: 6651 102nd Ave N, Pinnellas Park, FL 33782 Tel 877-569-8886 Fax 727-548-8622 Form PM1a2 - V2023-03
AC 10 AC 11
CITY & STATE
CITY & STATE
WO #:
AC 13 AC 14 AC 15 AC 16
AC 13 AC 14 AC 15 AC 16
AC 15 AC 16
AC 9 AC 10 AC 11 AC 12
AC 13 AC 14
FACILITY: Va Viera
CITY &
STATE
Viera
CUSTOMER: Va Viera
CITY &
STATE
Melbourne
PO#: NA JOB #: j67107
DATE: 3/4/2023 TECH: Miguel Ruiz
Affidavit j67107 Control # NA
All In One Certification Form - V2022-5.14
Medical Technology Associates Inc.
Certification
Medical Technology Associates
6651 102nd Ave N, Pinellas Park, FL 33782
Tel. (727) 535-3007, Fax (727) 548-8622
Certification
Affidavit #: j67107
Medical Technology Assications, Inc.
FACILITY:
CITY &
STATE
CUSTOMER:
CITY &
STATE
PO#: JOB #:
DATE: TECH:
OXY AIR VAC N2O N2 CO2 WAGD Other
Date
Viera
Melbourne
F. LEAK DETECTION
G. OTHER
A. TOTAL SYSTEM
EVALUATION
B. PATIENT OUTLET
TESTING
C. CONSTRUCTION
CERTIFICATION
D. CONTAMINANT TESTING
E. PARTICULATE MATTER
TESTING
CHECK APPROPRIATE BOX(ES)
MEDICAL GAS PIPING
SYSTEMS (A - G only)
Va Viera
Va Viera
NA
3/4/2023 j67107
Miguel Ruiz
Comments:
6651 102nd Ave N, Pinellas Park, FL 33782 | Tel. (727) 535-3007, Fax (727) 548-8622 | Form 100 - V2022-5.14
3/4/2023 Mccloskey mechanicalDominic Calloway
(Print)
CompanyService Acknowledged By Signature of
Responsible Facility Authority
Acknowledgement of Services certification_zone
Affidavit #: j67107
Medical Technology Associates, Inc.
FACILITY:
CUSTOMER:
PO#:
DATE:
Individual Pressurization (5.1.12.4.3.1) ✔ Pressure Differential (5.1.12.4.3.2)
Oxy P P P P P 50 40 60 P P P P
Vac P P P P P 29 12 NA P P P P
P = Pass; F = Fail, SC = See Comment
NA
Viera
Comments:
Va Viera
Va Viera
3/4/2023
ZONE
VALVE
BOX
Location:
Area Served:
AREA
ALARM
PANEL
Area Served:
Standing
Pressure
Test
Pressure
Gauges
Cross
Connection
Test
Insde room
G108 and G109
System
Line
Pressure
Low
Alarm High Alarm
Audible
Visual
Signals
Test
Switch
Sensor
Location
Pass / Fail
6651 102nd Ave N, Pinellas Park, FL 33782 | Tel. (727) 535-3007, Fax (727) 548-8622 | Form 102 - V2022-5.14
CITY &
STATE
CITY &
STATE
JOB #:
TECH: Miguel Ruiz j67107
Melbourne
Pass /
Fail
CROSS CONNECTION TEST (Check methodology)
Location:Right of entry
G108 and G109
Gas / Vacuum Proper
Labeling
Pass /
Fail
Medical Gas & Vacuum Zone Valve & Alarm Panel certification_field_affidavit
Affidavit #: j67107
Control Number: NA
Medical Technology Associates, Inc.
I, P System Inspection Per NFPA99 2021 5.1.12.3 has been completed.
Miguel Ruiz 3/4/2023 accordance with NFPA99 2021 and attest to the following:
Area Inspected: G108 and G109
Check appropriate box(es)
P
NA
DATE:
FACILITY: Va Viera
CITY &
STATE
Viera
TECH: Miguel Ruiz
P
P = Pass, F = Fail, NA = Not Applicable
P
P
P
NFPA99 2015
Antonio Ayala Certificate #: 12491804
Installer Performed Tests Per NFPA99 2021 Code 5.1.12.2 have been completed.
Verifier cross connection test was successfully completed.
Name: Certificate # :
Pipeline system tested was purged of the test gas Nitrogen (NF).
P
All tested outlets and inlets are labeled and functioning properly for flow and pressures.
All tested alarm panels were located and functioning properly.
All tested valves and zone valve boxes were located properly with tags and labels.
CUSTOMER: Va Viera
CITY &
STATE
Melbourne
PO#: NA
3/4/2023
Associates as of (date) , as a current appointed representative of Medical Technology have conducted tests of the Medical Gas & Vacuum System in
JOB #: j67107
P
P
Any equipment not listed on the attached worksheets is the responsibility of the Contractor and / or Facility.
P
All tested central supply systems were found to be properly located and functioning for their intended use.
If this box is "X'ed" review all notes on the MTA CODE COMPLIANCE WORK SHEET before patient use.
Verifiers 10 minute standing pressure test was successfully completed.
The concentration of the gas delivered at each outlet was tested and is within specified standards.
Category 3
Verifier is ASSE 6030 qualified per NFPA99 2021 5.1.12.4.1.3
Verifier is ASSE 6035 qualified per NFPA99 2021 5.1.12.4.1.4
NFPA99 2018 NFPA99 2021✔ Other
NFPA99 2012Category 1 Category 2
6651 102nd Ave N, Pinellas Park, FL 33782 | Tel. (727) 535-3007, Fax (727) 548-8622 | Form 104 - V2022-5.14
Signed (Contractor):Signed (MTA, Inc.): Signed (Responsible Facility Authority):
supply systems) at a later date.
NA
NA
piping system (including but not limited to inlets / outlets, alarm panels, zone valve boxes, manifolds or central
Medical Technology Associates, Inc will be held harmless from any liability caused by any modification of the
All tested air compressor and vacuum pumps were inspected and are installed correctly.
The above certification applies to the condition of the detailed, itemized list of equipment as of the date noted.
Hold Harmless Clause:
The Contractor and / or Facility are responsible for the identification of all the equipment to be certified.
Field Affidavit Inspection / Testing Services
Medical Gas & Vacuum Systems certification_outlet_b
Affidavit #: j67107
Medical Technology Associates, Inc.
W Oxy Y P
W Vac Y NA
W Oxy Y P
6651 102nd Ave N, Pinellas Park, FL 33782 | Tel. (727) 535-3007, Fax (727) 548-8622 | Form 105N - V2022-5.14
Pass
Fail
G108
Adjacent Inlet Test
(Vacuum)
Pressure
>12” Hg
3.0
(SCFM)
>5.0
NA >12
<5.0 >6 NA NA
Operational Pressure Test
(Gases)
Trans Flow Test
(SCFM)
Drop
(PSIG)
NA
Test
Gas
Purge
Test Flow 3.5
(5.0 N2) SCFM
Type of
Gas
Station
W,D,P,C
Location
G109 >5.0
AREA:
FACILITY:
CUSTOMER:
G108 and G109
Va Viera
Va Viera
3/4/2023
Miguel Ruiz
** Station Abbreviations: **W = Wall **D = Hose Drop **P = Pedestal **C = Arm, Boom, Column or Pendant
NA = Not Applicable / ND = None Detected / P = Passed / F = Failed / SC = See Comment
DATE:
TECH:
NA NA >3.0
<5.0 >6 NA
Additional Outlets may be continued on following sheets.
Comments:
Medical Gas & Vacuum Outlets certification_particulate
Affidavit #: j67107
Medical Technology Associates, Inc.
OXYGEN
FACILITY: Va Viera
CITY &
STATE
Viera
CITY &
STATE
Melbourne CUSTOMER: Va Viera
PO#: NA
Pass or Fail
NA
P
JOB #:
TEST CONDITION TEST RESULT
DATE: 3/4/2023 TECH:
NITROUS
OXIDEOXYGEN
MEDICAL
AIR
Miguel Ruiz
NITROGEN /
Instrument j67107
CARBON
DIOXIDE
P = Pass / F = Fail / NA = Not Applicable / ND = None Detected / SC = Source / N = N2 NF
NITROUS
OXIDE
NITROGEN /
Instrument
NA
NA
CARBON
DIOXIDE ZONE LOCATION and ROOM NUMBER
MEDICAL
AIR
G108
NA NANA NA
NA
NA
No Discoloration on filter
SC NA NASource (SC) or N2 NF (N)
< 1.0 MG Particulate Matter P NA
Test Gas Used
Pass or Fail
NAP NA NA NA
6651 102nd Ave N, Pinellas Park, FL 33782 | Tel. (727) 535-3007, Fax (727) 548-8622 | Form 112 - V2022-5.14
Medical Gas Particulate Test
Maintenance Interval - pick one Quarterly PM Semi-Annual PM Quarterly and Annual PM One-Time PM Location in facility Temp in equipment room °F Manufacturer Accessories Model Number Serial Number Drawing, Job or Q Number
Motor Plate Info: Amps SF Rated Voltage HP
Voltage Readings: Lead 1-2 Check here if single phase Lead 1-3 Lead 2-3
Amperage Readings:
Lead 1 Lead 2 Lead 3
Visual Checks:
Rotation Oil Level Hours Overloads set at H-O-A Switch Pump Temp °F Max Vac inches hg Vane Width*
*applies to dry rotary vane pumps only
Pressure Switch Settings:
On Off
Other Operating Parameters:
Horn audible Pumps alternate correctly Panel lights functional Motor bearings lubed Bypass correctly set Gearcase oil level checked Touch screen functioning Intake Filters checked All screw terminals tightened in control panel; control panel checked for arcing _________
Oil / filter changed Exhaust Filters changed Site Glasses Cleaned Check Valves Function Lag alarm operating Control Cabinet Filter Clean
Exhaust outlet screen checked for silncer debris (only applies to Rietschle and Busch dry claw vacuum pumps)
Pump 1 Pump 2 Pump 3 Pump 4
Pump 1 Pump 3Pump 2 Pump 4
PREVENTATIVE MAINTENANCE SERVICE REPORT
VACUUM SYSTEM
Lag 3
FACILITY
DATE
PO #
CUSTOMER
"" or "Y" = Yes or OK, "X" or "N" = No or Not OK, "-" or "N/A" = Not Applicable NOTE: All fields do not apply to all installations.
TECH:
Medical Technology Associates, LLC Corporate Office: 6651 102nd Ave N, Pinellas Park, FL 33782 Tel 877-569-8886 Fax 877-787-3220 Form PM1b2 v2023-03
Future service needs and/or service notes:
MTA SERVICE TECHNICIAN DATE
CITY & STATE
CITY & STATE
WO #:
Lead
RESPONSIBLE FACILITY AUTHORITY DATE
Lag 1 Lag 2
Amperage Readings:
Lead 1 Lead 2 Lead 3
Visual Checks:
Rotation Oil Level Hours Overloads set at H-O-A Switch Pump Temp °F Max Vac inches hg Vane Width*
*applies to dry rotary vane pumps only
Pressure Switch Settings:
On Off
VACUUM SYSTEM
PREVENTATIVE MAINTENANCE SERVICE REPORT
Pump 5 Pump 6 Pump 7 Pump 8
Pump 5 Pump 6 Pump 8Pump 7
FACILITY
DATE
PO #
CUSTOMER
"" or "Y" = Yes or OK, "X" or "N" = No or Not OK, "-" or "N/A" = Not Applicable NOTE: All fields do not apply to all installations.
TECH:
Medical Technology Associates, Inc. Corporate Office: 6651 102nd Ave N, Pinellas Park, FL 33782 Tel 877-569-8886 Fax 727-548-8622 Form PM1b2 - 2023-03
CITY & STATE
CITY & STATE
WO #:
Lag 4 Lag 5 Lag 6 Lag 7
Project:
Attention:
Completed By:
Annual Medical Gas Certification
William Glover
Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
THESE DOCUMENTS CONTAIN THE CERTIFICATION REPORTS FOR:
Viera VA Outpatient Clinic 2900 Veterans Way
Melbourne, FL 32940
01/26/2023
11300 49th Str. No.
Clearwater, FL 33762
Ph: (800) 990-6372 Fax: (866) 348-9650 1 of 31 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:
Viera VA Outpatient Clinic 2900 Veterans Way
Melbourne, FL 32940
11300 49th Str. No.
Clearwater, FL 33762
Ph: (800) 990-6372 Fax: (866) 348-9650
2 of 31 Pages
This certificate is issued - 01/26/2023 by Mercury Medical®.
This certificate relates to the work performed pursuant to a request for testing services by - Viera VA Outpatient Clinic
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 - Viera VA Outpatient Clinic located in - Melbourne, 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 31 Pages
Section 2
Facility Name: Viera VA Outpatient Clinic
Address:
Melbourne, FL 32940
Project Name: Annual Medical Gas Certification Test Date: 01/26/2023
Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for MEDICAL AIR COMPRESSOR Source
Enclosure/Location: Mechanical Room Critical Care Branch: EQDP-38, 40, 42
Package Model # : MTSD03034KS Serial #:
Type: Scroll RPM: 1400
HP: 3 Voltage: 460
Total Compressors in Package: 2 # Operational: 2
Main Line Pressure is: 52 Capacity: 9.5 SCFM @ 50 PSI
Lead Pressure Switch Cut in: 98 Cut Out: 110
Lag Pressure Switch Cut in: 105 Cut Out: 115
Actual Wired to Monitors Mfr. Serial # Reading Master
Dewpoint Powerex (H)05/20/16 69°F Yes CO Enmet 300-3195 0 Yes Dryers Powerex 0087 Pre Filters Wilkerson FRP96639 Pre Filters Wilkerson MSP96647
Filter Analysis 250 CO2 PPM 0
Recommendations:
Discrepancy:
F1803SHLO
A1804BL00
Hydro Carbon PPM
PMD10T00AJ
MEDICAL AIR COMPRESSOR SOURCE DATA
2900 Veterans Way
Model #
PDPM1001AJ
Co-Guard
(H)05/20/16-5926690-771
11300 49th Str. No.
Clearwater, FL 33762
Ph: (800) 990-6372
4 of 31 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: Med Gas room (dock) Critical Care Branch: EQDF 13, 15, 17
Package Model # : 1DRB7.5T200 Serial #: 125309812
Type: Rotary Lubed RPM: 1760
HP: 7.5 Voltage: 460 FLA: SF:
Total Vac Pumps in Package: 2 # Operational: 2
Source Line Vacuum is: 29 " Hg Capacity: 43 SCFM Each @19 IN
Lead Pressure Switch Cut in: 19 Cut Out: 24
Lag Pressure Switch Cut in: 16 Cut Out: 20
Comments:
Recommendations:
Discrepancy:
VACUUM SOURCE DATA
2900 Veterans Way Melbourne, FL 32940
01/26/2023
11300 49th Str. No.
Clearwater, FL 33762
Ph: (800) 990-6372
5 of 31 Pages
Section 4
Address:
Melbourne, FL 32940
Project Name: Annual Medical Gas Certification Test Date: 01/26/2023
Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for Oxygen Primary & Secondary Supply
Enclosure/Location: Med Gas Room (dock) Critical Care Branch: LLD 16
Manifold Manufacturer is: Amico
Model #: MTLTDHHUOXY Serial #: 981123-D
Liquid /Gas: Gas
6 Right Bank: 6
Main Line Manifold Pressure: 52 PSI
Manifold Right Bank Pressure: 600 PSI
Manifold Left Bank Pressure: 2200 PSI
Comments:
Recommendations:
Discrepancy:
OXYGEN MANIFOLD SOURCE DATA
2900 Veterans Way
Cylinders in Left Bank:
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 6 of 31 Pages
Address:
Melbourne, FL 32940
Project Name: Annual Medical Gas Certification Test Date: 01/26/2023
Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for Nitrous Oxide Primary & Secondary Supply
Enclosure/Location: Med Gas Room (dock) Critical Care Branch: LLD 14
Manifold Manufacturer is: Amico
Model #: MTLTDHHUOXY Serial #: 981123-D
Liquid /Gas: Gas
2 Right Bank: 2
Main Line Manifold Pressure: 51 PSI
Manifold Right Bank Pressure: 400 PSI
Manifold Left Bank Pressure: 680 PSI
Comments:
Recommendations:
Discrepancy:
NITROUS OXIDE MANIFOLD SOURCE DATA
2900 Veterans Way
Cylinders in Left Bank:
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 7 of 31 Pages
Address:
Melbourne, FL 32940
Project Name: Annual Medical Gas Certification Test Date: 01/26/2023
Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456 This data is for Nitrogen Primary & Secondary Supply
Enclosure/Location: Med Gas Room (dock) Critical Care Branch: LLD 18
Manifold Manufacturer is: Amico
Model #: M2HD-D-HH-NIT Serial #: 981127-D
Liquid /Gas: Gas
2 Right Bank: 2
Main Line Manifold Pressure: 173 PSI
Manifold Right Bank Pressure: 1800 PSI
Manifold Left Bank Pressure: 1500 PSI
Comments:
Recommendations:
Discrepancy:
NITROGEN MANIFOLD SOURCE DATA
2900 Veterans Way
Cylinders in Left Bank:
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 8 of 31 Pages
Section 5
MASTER ALARM DATA
Facility Name: Viera VA Outpatient Clinic
Address:
Project Name: Annual Medical Gas Certification Test Date: 01/26/2023 Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Critical Care Branch: LLD CKT 18 _________________________________ Setpoint
YES NO YES NO
X 40 X X 40 X X 40 X X 140 X
X 12 X
X 60 X X 60 X X 60 X X 195 X
N/A N/A N/A N/A N/A N/A
Local Visual Local Audible Local Alarm Only
X X X
X X X
X X X
X X X Local Visual Local Audible Local Alarm Only
X X X
X X
Comments:
Recommendations:
Discrepancy:
Vacuum Pumps Wired To Master Not Wired To Master
High Temp X Lag Pump Running X
X
Lag Compressor Running X
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
Secondary Low Head Pressure
X
Carbon Monoxide High (<10ppm) X
Compressor High Air Temp (Note14)
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
Secondary Supply In Use
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
2900 Veterans Way Melbourne, FL 32940
Manufacturer: Amico Alert 1
Enclosure Location: Biomed Gas Labeled Functioning
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 9 of 31 Pages
Section 5
MASTER ALARM DATA
Facility Name: Viera VA Outpatient Clinic
Address:
Project Name: Annual Medical Gas Certification Test Date: 01/26/2023 Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Critical Care Branch: LLD CKT 18 Setpoint
YES NO YES NO
X 40 X X 40 X X 40 X X 140 X
X 12 X
X 60 X X 60 X X 60 X X 195 X
N/A N/A N/A N/A N/A N/A
Local Visual Local Audible Local Alarm Only
X X X
X X X
X X X
X X X Local Visual Local Audible Local Alarm Only
X X X
X X
Comments:
Recommendations:
Discrepancy:
2900 Veterans Way Melbourne, FL 32940
Manufacturer: Amico Alert 1
Enclosure Location: Biomed 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
Secondary Supply In Use
Medical Air Compressor Wired To Master Not Wired To Master
Dew Point High ( 39F@50psig)
Secondary Liquid Level Low
Secondary Low Head Pressure
X
Carbon Monoxide High (<10ppm) X
Compressor High Air Temp (Note14) X
Lag Compressor Running X
Air Receiver High Water (Note15)
Liquid Ring Comp High Water (Note16)
Vacuum Pumps Wired To Master Not Wired To Master
High Temp X Lag Pump Running X
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 10 of 31 Pages
Section 6
Floor: Facility Name:
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 29 Yes
EVAC
Other
O U T L E T S
Yes 2 - Nitrous Oxide 10 - Leaking outlet 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
ALARM DATA O - Oxygen Zone Valve Value Data A - Medical Air
N - Nitrogen Yes E - EVAC (WAGD)
Medical Air
Zone Gases Installed Correctly
Gauges Present
Alarm PSIG or Hg
V - Vacuum C - Carbon Dioxide x Non-Critical Area Outside E504 E504 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x Area alarm data alarm N/A
Zone Valve Location:
Areas Served □ Critical Area (Alarm Required)
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023
Ox yg en
SC
FM
3.
M ed ica l A ir
SC
Ni tro us
Ox ide
SC
Ni tro ge n
SC
FM
Ca rb on
Di ox ide
SC
Va cu um
SC
W
AG
D
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 P 1 PE504 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = psig Vacuum = 28 psig 99% Nitrous Oxide = 50 psig EVAC = psig 99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F
□ P P P P
Comments:
Recommendations:
Discrepancy:
Gas
Pa rti cu la te m g no n-
M et ha ne
H yd ro ca rb on s pp m
*P/F = Pass/Fail AmicoAmico
Attached Outlet Data sheet for this zone.
Actual Static Pressure
H al og en at ed hy dr oc ar bo ns p pm
D ew
P oi nt
F
Actual Static PressureGas
Ohmeda
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 11 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 29 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside E505 E505 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 P 1 PE505 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = psig Vacuum = 28 psig 99% Nitrous Oxide = 50 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 12 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 29 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside E507 E507 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 P 1 PE507 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = psig Vacuum = 29 psig 99% Nitrous Oxide = 50 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 13 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside E508 E508 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 P 1 PE508 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = psig Vacuum = 29 psig 99% Nitrous Oxide = 50 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 14 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside E509 E509 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 P 1 PE509 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = psig Vacuum = 29 psig 99% Nitrous Oxide = 50 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 15 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside E512 E512 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 P 1 PE512 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = psig Vacuum = 28 psig 99% Nitrous Oxide = 50 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 16 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside E513 E513 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 P 1 PE513 Not in use
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 = psig 99% Carbon Dioxide = psig 21% Medical Air = psig Vacuum = psig 99% Nitrous Oxide = psig EVAC = psig 99% Nitrogen = psig Other = psig *P/F *P/F *P/F *P/F
□ N/A N/A N/A N/A
Comments: Not in use
Recommendations:
Discrepancy:
Amico Amico Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 17 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 51 Yes Nitrogen Carbon Dioxide Vacuum 25 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Hallway B118, B121, B208, B209
B313, B316 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 PB118 Good 1 P 1 P 1 PB121 Good 1 P 1 P 1 PB208 Good 1 P 1 P 1 PB209 Good 1 P 1 P 1 PB315 Good 1 P 1 P 1 PB316 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = 50 psig Vacuum = 29 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 18 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes
Nitrous Oxide 50 Yes Nitrogen Carbon Dioxide Vacuum 29 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Nurses Station B332, B412, B410, B414 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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 N - Nitrogen
Yes 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 PB332 Good 2 P 2 P 2 PB410 Good 2 P 2 P 2 PB412 Good 2 P 2 P 2 PB414 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = 50 psig Vacuum = 29 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 19 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes 50 Yes
Nitrous Oxide Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside C104 C102, C108, C122, C123 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.
Notes
2 P 2 P 2 PC102 Good 1 P 1 P 1 PC108 Good 1 P 1 P 1 PC122 Good 1 P 1 P 1 PC123 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = 50 psig Vacuum = 28 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 20 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes 50 Yes
Nitrous Oxide Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside C115 C115 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.
Notes
1 PC115 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = 50 psig Vacuum = 28 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 21 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes 50 Yes
Nitrous Oxide Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside C117 C117, C116 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 PC117 Good 1 P 1 P 1 PC116 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = 50 psig Vacuum = 28 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 22 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes 50 Yes
Nitrous Oxide Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area Outside C119 C119, C120 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
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 PC119 Good 1 P 1 P 1 PC120 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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = 50 psig Vacuum = 28 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 Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 23 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes 50 Yes
Nitrous Oxide Nitrogen Carbon Dioxide Vacuum 28 Yes
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023 x Non-Critical Area C406 C406 □ (If applicable) Manufacturer/Model -
Alarm Location: _____________________ x 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
Ox yg en
SC
M ed ica l A ir
SC
Ni
SC
Ni tro ge n
SC
FM
Ca ide
SC
Va cu um
W
AG
D
Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/F Qty *P/FRoom No.
Notes
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 = 52 psig 99% Carbon Dioxide = psig 21% Medical Air = 50 psig Vacuum = 28 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: Not in use
Recommendations:
Discrepancy:
Amico Amico Ohmeda no n-
M et ro ca rb on s pp m
H al og en oc ar bo ns p pm
D ew
P oi nt
F
Attached Outlet Data sheet for this zone.
*P/F = Pass/Fail
Gas Actual Static Pressure Gas
Actual Static Pressure
Pa rti cu la te m g
11300 49th Str. No.
Clearwater, FL 33762
Fax: (866) 348-9650 24 of 31 Pages
1st Address:
Building: Test Date:
Main Technician: Frank D'Arpa - Medical Gas Certifier - N.I.T.C. # 12313456
Notes/Legend:
Setpoints | Functioning
PSIG
or Hg Low High Yes No
Oxygen 52 Yes 52 40 60 52 Yes 50 40 60
Nitrous Oxide Nitrogen Carbon Dioxide Vacuum 26 Yes 26 12 N/A
EVAC
Other
O U T L E T S
ZONE / ALARM / OUTLETS DATA SHEET
Viera VA Outpatient Clinic 2900 Veterans Way Melbourne, FL 32940 01/26/2023
□ Non-Critical Area C321 Recovery 1-5
C321 X (If applicable) Manufacturer/Model -
Alarm Location: Amico LED
Nurses Station □ Area alarm data alarm N/A
Zone Valve Location:
Areas Served x 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
Ye…
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