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Dr. Babin, DDS & Associates-3267-8.9.21Medical Gas Services 918 S Horton St, Suite 917 Seattle, WA 98134 medgasservices.io (42S) 894 5918 Dental Air and Vacuum Verification Report Date: August llth, 2021 Job Number: 3267 Contractor: Bulldog Plumbing Date(s) / Time(s) of Testing: August 9th, 2021- 0900 hrs. Facility: Dr. Babin, DDS S Associates 7631 212th St SW, Suite 109C Edmonds, WA 98026 Scope of Work: Installation of 3 new chairs to existing dental air and vacuum distribution system Our firm certifies that the verifier named in the report is properly trained and certified to perform the activities required. All testing and measurement equipment are 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. Dental air and vacuum are in compliance with NFPA 99(2012ed): Category 3 Dental B. No crossed lines were found in dental air and vacuum in the area tested on the day of testing. C. Dental air meets oxygen concentration, D. Dental air meets pressure requirements. E. Dental vacuum meets vacuum level requirements. F. Dental air and vacuum system components in area tested are in compliance with NFPA 99(2012ed): Category 3 Dental (See Note, Comments and Recommendations) Note: Existing Equipment and Systems NFPA 99 (2012e d) 115114 - An existing Category 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 havingjunsdiction has determined that such use does not constitute a distinct hazard to life. 3267-8.9.21-VR Pg. 1 of 3 Medical Gas Services 918 S Horton St, Suite 917 Seattle. WA 98134 medsasservices.io (425) 894 5918 II. Dental Air: A. Static Line Pressure: 115 psig B. Concentration of Oxygen: 20.3% III. Dental Vacuum: A. Static Line Vacuum: 9.5" HgV IV. Particulate Line Testing: PASS V. Odor: None -PASS VI. Dental Equipment: A. Dental Air: 1. System air components are in compliance with NFPA 99(2012ed) 2. Brand Name: AirTechniques 3. Model Number: AS22M 4. Serial Number: 241630 5. Configuration: Simplex 6. Horsepower: 1.5 hp 7. Air Intake: Inside(other) 8. Pump: Oil Less B. Dental Vacuum: 1. System vacuum components are in compliance with NFPA 99(2012ed) 2. Brand Name: AirTechniques 3. Model Number: VS80H 4. Serial Number: VS801-17120038 5. Configuration: Duplex 6. Horsepower: 4 hp 7. Exhaust Vented Outside: Yes C. Amalgam Separator: 1. Brand Name: Rebec 2. Model Number: N/A 3. Serial Number: J300136591-20 3267-8.9.21-VR Pg. 2 of 3 Medical Gas Services 918 S Horton St, Suite 917 Seattle. WA 98134 medsasservices.io (425) 894 5918 VII. Brazier: Brandon J Knopff A. Brazier Number: KNOPFBJ814KM B. Plumbing Contractor: Bulldog Plumbing VIII. Comments: A. None IX. Recommendations: A. None Tested By: Alexander Christensen - Medical Gas Technician Reviewed By: Matthew Waajchhsmuth - ASSE 6030. Verifier 3267-8.9.21-VR Pg. 3 of 3 Medical Gas Services 918 S Horton St, Suite 917 Seattle. WA 98134 medsasservices.io (425) 894 5918 Category 3 Verification Check List Reference NFPA 99(2012ed) Job #: 3267 Facility: Dr. Babin, DDS S Associates Tested By: AC Test Date: 8.9.21 Facility: ❑ New E Existing Type of Facility: E Dental ❑ Medical ❑ Veterinary ❑ Lab ❑ Other: Dental Equipment ❑ Not Tested Dental Air System: ❑ New E Existing ❑ NONE Dental Vacuum System: ❑ New E Existing ❑ NONE Brand: Ail -Techniques Brand: Ail -Techniques Model #: AS22M Model #: VS80H Serial #: 241630 Serial #: VS801-17120038 Conf: ® Simplex ❑ Duplex ❑ Triplex ❑ Quad Conf: ❑ Simplex ® Duplex ❑ Triplex ❑ Quad Compressor Type: Oil Less Pump Type: Oil Less Compressor On: 80 psi Compressor Off: 120 psi Vac Level: 9.5 "H9V Horsepower: 4 hp. Line Pressure: 115psi Particulate: ® Pass ❑ Fail Drain: ❑ Sealed ® Open ❑ Floor ® Wall Concentration: 20.3 % Horsepower: 1.5 hp. Flexible Connectors: ® Yes ❑ No Receiver: ® Yes ❑ No Drain: ® Manual ❑ Auto Air / Water Separator: ® Yes ❑ No Moisture Indicator: ® Yes ❑ No Exhausted to Outside: ® Yes ❑ No Dryer: ® Yes ❑ No Type: Desiccant Location of Discharge: Side Wall Intake: ❑ Outside ® Inside (other) ❑ Inside (same) Piping: ® Hard Copper ® Schedule 40 PVC Amalgam Separator ❑ New ® Existing ❑ Not Required ❑ None Brand: Rebec Model #: N/A Serial #: J300136591-20 Comments.- 3 new chairs added to existing system 3267-8.9.21 Pg.1 of 1