20180517071755.pdfMedical Gas Services, LLC
6355 NE 151st Street
Kenmore, WA 98028
425-877-9623
Medical Gas Line Verification
n
rX e P ort
Date: November 1, 2017
Contractor: PSF Mechanical
Date(s) / Time(s) of Testing: November 1, 2017 — 2045hrs
Facility: Edmonds Center for Outpatient Surgery
7320216 th ST. SW
#140
Edmonds, WA 98026
Scope of Work: Installation of (4) new oxygen outlets and (4) new medical vacuum inlets
Our firm certifies that the verifier named in the report is properly trained and certified to perform
the activities required. All test and measurement equipment is properly calibrated and
maintained. As a representative of Medical Gas Services LLC the verifier named in this report
has conducted testing and verification of medical gas piping systems and related equipment to
certify the following on the above date.
General Findings:
A. Medical gases and vacuum are in compliance with NFPA 99 (2012ed): Category 1
B. No crossed lines were found in medical gas or vacuum systems in the tested areas on
the day of testing.
C. Medical gases meet minimum concentration.
D. Medical gases meet minimum flow and are at normal pressure.
E. Medical vacuum meets minimum flow and is at normal vacuum pressure.
F. Medical gas system components in the area tested are in compliance with NFPA 99
(2012ed).
G. Medical Gas Line Purity Test: PASS
H. Purge Gas: Lot # T906670 (Central)
1. Permit #: BLD20171078 — City of Edmonds
J. Attachments: Work sheet
Note: Existing Equipment and Systems
NFPA 99(2012ed) #5.1.1.4 — An existing system that is not in strict compliance
with the provisions of this standard shall be permitted to be continued in use as
long as the authority having jurisdiction has determined that such use does not
constitute a distinct hazard to life.
EdmondsCOS-1 1. 1. 1 7-VR-Medical Gas Line (2012ed) Pg 1 of 3
Medical Gas Services, LLC
6355 NE 151st Street
Kenmore, WA 98028
425-877-9623
111. Medical Gases:
A. Oxygen:
1. Static Line Pressure: 50 psi
2. Dynamic Outlet Free Flow: >3.5 scfm
3. Oxygen Concentration: >99.0%
4. Delta Flow: PASS
111111. Vacuum:
A. Medical —Surgical Vacuum
1. Static Line Vacuum: 26" HgV
2. Dynamic Inlet Free Flow: 3.0 scfm
3. Delta Flow: PASS
IV. Particulate Test: PASS
V. Odor: None
V11. Outlets / Inlets: (New)
A. Brand: Amico
B. Quick Connect Style: Chemetron
Vil. Zone Valves: (Existing)
A. Brand: Allied
B. Down line gauges: Yes
C. Labeled for Area Controlled: No
Vill. Alarms:
A. Area Alarms: (Existing)
1 Brand: Allied
2. Labeled for Area Monitored: No
EdmondsCOS-1 1. 1. 1 7-VR-Medical Gas Line (2012ed) Pg 2 of 3
Medical Gas Services, LLC
63 55 N E 151 st Street
Kenmore, WA 98028
425-877-9623
IX. Brazier: Micah Synsteby
A. Brazier Number: SYNSTM*913ML
B. Contractor: PSF Mechanical
X. Witness: Keven Wesson — PSF Mechanical
X1. Comments:
A. Area alarm and zone valve are not labeled for areas monitored.
XII. Recommendations:
A. Label zone valve and alarm for areas monitored.
Tested By: David Pomeranz — Medical Gas System Technician
Reviewed By: Harry Pomeranz — ASSE 6030 Verifier
EdmondsCOS-1 1, 1. 1 7-VR-Medical Gas Line (2012ed) Pg 3 of 3
Medical Gas Services, LLC
Medical Gas Outlet / Inlets Evaluation Worksheet
Facility: Edmonds Center for Outpatient Surgery Job#: I Date: 11 /1 /17 - 2045
Area Tested: Pre/Post OP I Verifier: DP
7nnp Valvp - M Nnnp M Nnt Renuired M New l5a Existina
Labeled As: Not Labeled
I ZV Brand: Allied
Gas
3 Part Valve
DIL Gauge
Ga. PSI
Act PSI
Comments:
OX
0 Yes El No
0 Yes [--] No
52
50
MA
El Yes E3 No
El Yes Ej No
VAC
, E Yes El No
Z Yes El No
29
26
Aroa Alarm - F-1 None F�] ot Reauired r-1 New M Existina
Labeled As: Not Labeled
Brand: Allied
Gas
PSI
Set HI
Set LO
Sensor
Comments:
ox
50
60
40
DL
MA
28
60
40
DL
Outlats A Intats - 15ZI Now 171 Existina
Outlet I Inlets Brand: Amico
Location: Wall
I Quick Connect: Chemetron
Area Room I Door
Gas
Flow
SCFM
Delta
Flow
Conc.
%
Part.
Comments:
1
Ox
>10
P
>99
P
VAC
3
P
--
2
Ox
>10
P
>99
P
VAC
3
P
--
3
ox
>10
P
>99
P
VAC
3
P
--
4
Ox
>10
P
>99
P
VAC
3
P
--
EdmondsCOS-1 1. 1. 1 7-Datasht-Gas Outlet Page 1 of 1
Lab name: Certified Medical Testing
Client:
Client ID:
Collected:
Analysis date: 10/09/2017 15:11:47
Method: Valve Injection
Description: FID
Data file: tph24032.CHR
Sample: Calibration Run
Operator: Staff
Comments: Total Hydrocarbons as Methane Results
-2.225
L Methane/1.1900/PPM
2--
31-
HalogenatedHydroCarbon/l. I 700/ppm
4J L
5
Component
Area External Units
Methane 53.0540 1.1900 PPM
Halogenated HydroCartl 8.6235 1. 1700 ppm
71.6775 2.3600
Lab name: Certified Medical Testing
Client:
Client ID:
Collected:
Analysis date: 10/09/2017 15:11:47
Method: Valve Injection
Description: DELCD
Data file: tce24129.CHR
Sample: Calibration Run
Operator: Staff
Comments: Total Hydrocarbons as Methane Results
39.063 -172.267
12 L
Halo. Hydrocarbons/1.1700/PPM
4-
5'
Component Area External Units
Halo. Hydrocarbons 1803.1270 1.1700 PPM
1803.1270 1.1700
1319.075
Lab name: Certified Medical Testing
Client: Edmonds OP Surgery
Client ID: MGSS
Collected: 10.5.17
Analysis date: 10/09/2017 15:18:53
Method: Valve Injection
Description: FID
Data file: tph24033.CHR
Sample: 02 Line
Operator: Staff
Comments: Total Hydrocarbons as Methane Results
-2.225
JL Methane/0.1067/PPM
Component Area External Units
Methane 4.7575 0.1067 PPM
4.7575 0.1067
Lab name: Certified Medical Testing
Client: Edmonds OP Surgery
Client ID: MGSS
Collected: 10.5'� 17
Analysis date: 10/09/2017 15:18:53
Method: Valve Injection
Description: DELCD
Data file: tce24130.CHR
Sample: 02 Line
Operator: Staff
Comments: Total Hydrocarbons as Methane Results
39.063 -172.267
2-
3'
4
5
Component
Area External Units
0.0000 0.0000
1319.075
Medical Gas Services, LLC
6355 NE 151st Street
Kenmore, WA 98028
425-877-9623
Medical Gas Line Verification
Report
Date: January 30, 2018
Contractor: PSF Mechanical
Date(s) / Time(s) of Testing: January 29, 2018 — 2100hrs
Facility: Edmonds Center For Outpatient Surgery
7320216 th ST SW #140
Edmonds, WA 98026
Scope of Work: Installation of (3) Oxygen Outlets and (3) Medical Vacuum Inlets
Our firm certifies that the verifier named in the report is properly trained and certified to perform
the activities required. All test and measurement equipment is properly calibrated and
maintained. As a representative of Medical Gas Services LLC the verifier named in this report
has conducted testing and verification of medical gas piping systems and related equipment to
certify the following on the above date.
General Findings:
A. Medical gases and vacuum are in compliance with NFPA 99 (2012ed): Category 2
B. No crossed lines were found in medical gas or vacuum systems in the tested areas on
the day of testing.
C. Medical gases meet minimum concentration.
D. Medical gases meet minimum flow but are not at normal pressure.
E. Medical vacuum meets minimum flow and is at normal vacuum pressure.
F. Medical gas system components in the area tested are in compliance with NFPA 99
(2012ed).
G. Purge Gas: Lot # T0823701 (Central)
H . Permit #: BLD20171078 City of Edmonds
1. Attachments: Work sheet
Note: Existing Equipment and Systems
NFPA 99(2012ed) #5.1.1.4 — An existing system that is not in strict compliance
with the provisions of this standard shall be permitted to be continued in use as
long as the authority having jurisdiction has determined that such use does not
constitute a distinct hazard to life.
EdmondsCOS-1.30.18-VR-Medical Gas Line (2012ed) Pg 1 of 3
Medical Gas Services, LLC
6355 NE 151st Street
Kenmore, WA 98028
425-877-9623
II. Medical Gases:
A. Oxygen:
1. Static Line Pressure: 48 psi
2. Dynamic Outlet Free Flow: >6.0 scfm (for 3 seconds in'Critical Care Area')
3. Oxygen Concentration: >99.0%
4. Delta Flow: PASS
Ill. Vacuum:
A. Medical —Surgical Vacuum
1. Static Line Vacuum: 28" HgV
2. Dynamic Inlet Free Flow: >3.0 scfm
3. Delta Flow: PASS
IV. Particulate Test: PASS
V. Odor: None
VI. Outlets / Inlets: (New)
A. Brand: Amico
B. Quick Connect Style: Chemetron
VII. Zone Valves: (Existing)
A. Brand: Allied
B. Down line gauges: Yes
C. Labeled for Area Controlled: No
Vill. Alarms:
A. Area Alarms: (Existing)
1 Brand: Allied
2. Labeled for Area Monitored: No
IX Brazier: Micah Synsteby
A. Brazier Number: SYNSTM*913ML
B. Contractor: PSF Mechanical
X. Witness: James Conley — Ferris Turney
EdmondsCOS-1.30.18-VR-Medical Gas Line (2012ed) Pg 2 of 3
Medical Gas Services, LLC
6355 NE 151st Street
Kenmore, WA 98028
425-877-9623
X1. Comments:
A. Oxygen pressure was low on the day of testing.
B. Area alarm and zone valve not labeled for area monitored.
X11. Recommendations:
A. Set oxygen line pressure between 50-55psi.
B. Label zone valve and are alarm for area monitored.
Tested By: David Pomeranz — Medical Gas System Technician
Reviewed By: Harry Pomeranz — ASSE 6030 Verifier
EdmondsCOS-1.30.18413-Medical Gas Line (2012ed) Pg 3 of 3
Medical Gas Services, LLC
Medical Gas Outlet / Inlets Evaluation Worksheet
Facility: Edmonds Center for Outpatient Surgery Job #: Date. 1.29.18
Area Tested: Pre/Post --FVerifier: DP
Zone Valve - 171 None F-1 Not Reauired 171 New FA Existina
Labeled As: Not Labeled
I ZV Brand: Allied
Gas
3 Part Valve
DL Gauge
Ga. PSI
Act PSI
Comments:
OX
0 Yes El No
0 Yes D No
49
48
Oxygen line pressure low
MA
El Yes El No
El Yes El No
VAC
Z Yes El No
0 Yes E:1 No
30
28
Area Alarm - F-1 None F-1 Not Reauired F-1 New 15� Existina
Labeled As: Not Labeled
Brand: Allied
Gas
PSI
Set HI
Set LO
Sensor
Comments:
Ox
48
60
40
DL
MA
VAC
26.8
--
12
DL
Outlets & Inlets - 15� New 7 Existina
Outlet I Inlets Brand: Amico
Locatio :Wall
I Quick Connect: Chemetron
Area I Room I Door
Gas
Flow
SCFM
Delta
Flow
Conc.
%
Part.
Comments:
Pre/Post SC-1 16
Ox
>10
P
>99
P
VAC
6
P
--
PAC U SC-1 20
Ox
>10
P
>99
P
VAC
6
P
--
Pre/Post SC-1 15
Ox
>10
P
>99
p
VAC
6
P
--
Brazier: Micah Synsteby
Nitrogen T0823701
BLD20171078 City of Edmonds
Witness: James Conley — Ferris Turney
EdmondsCOS-1.29.18-Datasht-Gas Outlet Page 1 of 1