2458_001.pdfMedical Gas Services, LLC
Inspector of Record
Report
Date: September 5, 2019
Job Number: 2028
Contractor: Dr. Radu Wolf
Date(s) and Time(s) of Testing: September 3, 2019 — 0900 hrs.
Facility: Smile Again — Radu Wolf DDS
7935216 ffi Street SVV, Suite A
Edmonds, WA. 98026
Scope of Work: Verification of cylinder storage room modifications.
Medical Gas Services, LLC
6355 NE 151s' Street
Kenmore, WA 98028
425-877-9623
SEP 2 3 2019
LX-- VtJ-(-'PV ENT SERVICES
Our firm certifies that the verifier(s) named in the report are 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(s) named in this
report have conducted testing and verification of Medical Gas piping systems and related
equipment to certify the following on the above date.
1. General Findings:
A. Some Medical Gas and Dental system components in area tested are in compliance
with NFPA 99 (2012ed). Level 3, Dental.
Note: Existing Equipment and Systems.
NFPA 99(2012ed) #5.3.1.4 - An existing Level 3 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.
1796-1 nspectorOf Record Pg. 1 of 3
Med-ical Gas Servicesq LLC Medical Gas Services, LLC
6355 NE 151st Street
Kenmore, WA 98028
425-877-9623
111. Manifold /Alarm:
A. Manifold:
1. Brand: Porter
2. Model Number: Vanguard
3. Serial Number: 4-3591
B. Alarm:
1. Brand: Porter
2. Model Number: Vanguard
3. Serial Number: KD98526
111. Dental Equipment:
A. Dental Air:
1 . Most system air components in compliance with NFPA 99(2012ed)
2. Brand: Cattani
3. Model Number: CT-38/1
4. Serial Number: CA2000051
5. Configuration: Duplex
6. Horse Power: Unknown
7. intake: Inside (Same)
8. Pump: Oil Less
B. Dental Vacuum:
1 . Most system vacuum components in compliance with NFPA 99(2012ed)
2. Brand: Ramvac
3. Model Number: 809E-1050.1 (Bulldog)
4. Serial Number: QT1 101138
5. Configuration: Simplex
6. Horse Power: 1
7. Vented to outside, Yes
C. Amalgam Separator:
1. Brand: Solmetex
2. Model Number: Hg5
3. Serial Number: CC-L-386569
IV. Cylinder Storage:
A.
Location: Remote
B.
Ventilation: Yes
C.
Cooling Sprinkler: Yes
D.
Door labeled: Yes
E.
1 Hour Rated: No
F.
Cylinders Secured: Yes
1796-1 nspectorOf Record Pg. 2 of 3
Medical Gas Services, LLC
Medical Gas Services, LLC
6355 NE 151st Street
Kenmore, WA 98028
425-877-9623
V. Witness: Sophia Wolf — Smile Again
V11. Comments:
A. Interior finishes not made of non-combustible materials.
B. Natural ventilation does not have an opening within one foot of the floor.
V1111. Recommended Corrections:
A. Finish interior of cylinder storage room with non-combustible materials.
B. Relocate one ventilation opening to within one foot of the floor per NFPA 99.
Tested By: Harry Pomeranz — ASSE 6030 Verifier
1796-InspectorOf Record Pg. 3 of 3