Nitrox Final Letter.pdf12/50/2008 15:20 FAX 4257412500 NI'ROX INC
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Inc ■ Medical uses l, Medical Cas Lure Verifications - Analgesia iquipment
*** ME, DIC.A,L CAS LINE ***
CERTIFICATE OF VERIFICATION
08 DECEMBER 2008
CONTRACTOR: STEVENS HOSPITAL
DATE AND TIME OF TESTING_ 04 NOVEMBER 200812:15 P.M.
18 NOVEMBER 2008 ! 4.00 P.M.
FACILITY NAME: STEVENS HOSPITAL HYPERBARIC CLINIC
ADDRESS: 21911 — 76" AVE. WEST
EDMONDS, W.A.. 98026
AREA: NEW BULK, MEDICAL OXYGEN HYPERBARIC SYSTEM.
TESTING BY: B. EVAN Mc ALLISTER / ERIC BERT - NITROX INC.
OUR FIRM CERTIFIES THAT THE ABOVE NAMED PERSON IS PROPERLY TRAINED
AND CERTIFIED TO PERFORM THE ACTIVITIES REQUIRED. ALL TEST AND
MEASUREMENT EQUIPMENT -TS -PROPERLY CALIBRA:'IED A:ND MAINTAINED.
AS A REPRESENTATIVE OF NITROX INC. THE ABOVE NAMED VERIFIER HAS
CONDT)CTED TESTING AND VERIFICATION OF THE MEDICAL GAS PIPING SYSTEM
AND RELATED EQUIPMENT TO CERTIFY THE F'OLLOWIN'G ON THE DATE ABOVE.
FINDINGS:
A_ ALL VALVES ARE PROPERLY LOCATED, TAGGED, AND FUNCTIONING
PROPERLY.
B. ALL ALARM PANELS AND DEVICES ARE PROPERLY LOCATED AND
TESTED, SIGNALS F1J`NCT1ON AT PROPER SET POINTS.
C. SUPPLY GAS SYSTEMS ARE PROPERLY LOCATED AND WERE
SEQUENCED,
STEVENSITYPERCLINIC- 11.04.08ag
// 2706 164th Street 5.W., Lynnwood, WA 98087
{ �'0 . } (425) 741-8807 - 1-800-736-7047 ■ Fax. (42 5) 741-2 500
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I. CONTINUED:
D. ALL EQUIPMENT AND FITUNGS WERE APPROPRIATELY PRE CLEANED
i OR CLEANED ON SITE -
E. ALL BRAZING WAS CONDUCTED IN ACCORDANCE WITH STANDARDS.
F. BULK OXYGEN SYSTEM IS PR.OI'ERLY LABELED AND/ OR "COLOR
CODED"-
G. PURGE WAS CONDUCTED USING NITROGEN Nr AND PASSES NFPA
wfUTE CLOTH TEST. - PASS
ff. SYSTEM MEETS .APPLICABLE CROSS CONNECTION TESTS. PASS
1, SYSTEM PASSES INITIAL 150 PSIG. PRESSURE TEST: -PASS
T. SYSTEM PASSES APPLICABLE FLOW TEST FOR NFPA 99 (CURRENT
REVISIONS)_ LASS
IT. PRODUCT ANALYSIS PRIOR TO SYSTEM GONG ON LINE:
A. OXYGEN PURITY (Va) - USP >99.0% / ACTUAL 99.7 Vo
B . CARBON:DIO E.{pVm)._<3.00...V.pm.. _./.ACTU.AL: PASS - NT
C. CARBON MONOXIDE (ppm.) <10 ppm / ACTUAL: PASS -NT
D, ODOR (PASS OR FAIL) / ACTUAL; PASS
E. DEW POINT (NITROGEN) PURGE (5C tr��x 50 PSIG) ACTUAL; PASS (40TH)
F. PARTICULATE 0,45 MICRON FILTER FOR 1000L @ 3.5 SCFM: PASS
G. TOTAL HYDROCARBONS AS METHANE <1 ppm / PASS * See Report
H. HALOGENATED HYDROCARBONS t2 ppm / PASS: PASS * See Report
I. PURITY (N)# PL09V291A (AG)
NO'T'E: NT= NOT DETECTABLE OR BELOW LEVEL OF EQUIPMENT.
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2706 164th Street S.W., Lynnwood, WA 98087
C.i
(425) 741-8807 ■ 1-800-736-7047 ■ Fax: (425) 741-2540
12/30/2448 19:20 FAX 4257412500 NITROX INC 0005
-M "*P Inc ■ Medica! Gases • Medical Gas Lime verifications ■ Analgesia Equipment
T EVAN Mc ALLISTER - CRTT, CMGV
PRESIDENT
STEVENSITYPERCLiNIC-11.04.08ag PO of "a
2706 164th Street S.W., Lynnwood, WA 98087
(425) 741-880'7 • 1-800.736-7047 • Fax -.(425)741-2500
J IIi.
5ULI, MEDICAL OXYGEN SYSTEM:
3
A. MAIN TANK: `MVE'- GALS: 1500 -SCR. BUILT: 2003
;
1, NAT BD: # 64098, SN: # 15315, MDL: # VS-1500--NC250
'
B, BACK UP CYLINDERS: HI TH PRESSURE'- (6 ca. CYLINDERS)
1. `CTR' 6.
!
C. MANIFOLD: `CTR'- Built: 2006
1. MI3L: #101608 — 6, SN: x#081049
D. ALARM: `CTR'- ON PEDESTAL
1. MAL: NEPA 99
E. VAPOIERS: "CRYOGENICS EXPERTS' - SCFH: 2000 - MAWP: 500 Psig.
"YR BUILT- 2009
1. MDL: ##A4A-SL-MF, SN: #080933, PN: 4101922405
1V.
BRIER, SOON BY2EBNER - TITLE IX, AWS, AS SE 6015, AIRGAS
VT.
WITNESS: STEPHAN REBNELDT — CONSTRU11ON MANGER
VTI.
COMMENTS:
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-A.-NONE
VI11
RECOMMENDED CORRECTIONS:
A. NONE
T EVAN Mc ALLISTER - CRTT, CMGV
PRESIDENT
STEVENSITYPERCLiNIC-11.04.08ag PO of "a
2706 164th Street S.W., Lynnwood, WA 98087
(425) 741-880'7 • 1-800.736-7047 • Fax -.(425)741-2500