SI REPORT Distinctive Dentistry-3314-9.7.21(Medical Gas Services
918 S Horton St, Suite 917
Seattle, WA 98134
medgasservices.io
(425) 894 5918
Dental Gas Line Verification Report
Date: September 9th, 2021
Job Number: 3314
Contractor: Local Plumbing S Construction
Date(s) and Time(s) of Testing: September 9th, 2021- 0600 hrs.
Facility: Distinctive Dentistry
22815 Edmonds Way
Edmonds, WA 98020
Scope of Work: New Medical Gases, Dental Air and Vacuum
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. Medical Gases are in compliance with NFPA 99(2012ed):
Category 3, Dental - "NOT FOR ANESTHESIA"
B. No crossed lines were found in Medical Gases in the tested areas on the day of
testing.
C. Medical Gases meet minimum concentrations.
D. Medical Gases are at normal pressure.
E. Dental Air is at normal pressure.
F. Dental Vacuum is at normal level.
G. Medical Gas and Dental system components in area tested are in compliance with
NFPA 99 (2012ed).
Category 3, Dental.
H. City of Edmonds: Permit # 27033600102706
I. Attachments: Worksheets
Note: Existing Equipment and Systems
NFPA 99(2012ed)1153.14 - 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 havingiunsdiction has determined
that such use does not constitute a distinct hazard to life.
3314-9.7.21-VR Pg.1 of 4
(Medical Gas Services
918 S Horton St, Suite 917
Seattle, WA 98134
medsasservices.io
(425) 894 5918
II. Medical Gases
A. Oxygen:
1. Static line pressure: 52 psig.
2. Oxygen concentration at outlet: 97.8%
3. Dynamic outlet free flow at outlet: >3.5 scfm
B. Nitrous Oxide:
1. Static line pressure: 50 psig.
2. Nitrous Oxide concentration at outlet: >99%
3. Dynamic outlet free flow at outlet: >3.5 scfm
III. Dental Air and Vacuum:
A. Dental Air:
1. Static line pressure: 105 psig.
2. Oxygen concentration at outlet: 20.7 %
B. Dental Vacuum:
1. Static line vacuum: 15 "HqV.
IV. Particulate Line Test: PASS
V. Odor: PASS
VI. Outlet:
A. Outlet Style: DISS
VII. Manifold / Alarm:
A. Manifold:
1. Brand: Belmed
2. Model Number: N/A
3. Serial Number: N/A
B. Alarm:
1. Brand: Belmed
2. Model Number: N/A
3. Serial Number: N/A
3314-9.7.21-VR Pg. 2 of 4
(Medical Gas Services
918 S Horton St, Suite 917
Seattle, WA 98134
medgasservices.io
(425) 894 5918
VIII. Dental Equipment:
A. Dental Air:
1. System air components in compliance with NFPA 99(2012ed)
2. Brand: TechWest
3. Model Number: ACOR202
4. Serial Number:11018
5. Configuration: Duplex
6. Horsepower: 1.5 hp
7. Intake: Outside
8. Pump: Oil Less
B. Dental Vacuum:
1. System vacuum components in compliance with NFPA 99(2012ed)
2. Brand: TechWest
3. Model Number: VPD252
4. Serial Number: VPD2-7337
5. Configuration: Simplex
6. Horsepower: 1 hp
7. Vented to outside.
C. Amalgam Separator:
1. Brand: Solmetex
2. Model Number: NXT-HG5-001
3. Serial Number: NXT69890
X. Cylinder Storage:
A.
Location: Inside
B.
Ventilation: Natural
C.
Cooling Sprinkler: Yes
D.
Door labeled: Yes
E.
1 Hour Rated: Yes
F.
Cylinders Secured: Yes
3314-9.7.21-VR Pg. 3 of 4
(Medical Gas Services
918 S Horton St, Suite 917
Seattle, WA 98134
medsasservices.io
(425) 894 5918
XI. Brazier: Jose Villagrana
A. Brazier Number: VILLAJ`849PO
B. Plumbing Contractor: Local Plumbing S Construction
XII. Comments:
A. Dental vacuum drain is sealed into floor
XIII. Recommended Corrections:
A. Install an open drain or confirm a sealed drain is acceptable with authority having
jurisdiction
Tested By: Alexander Christensen - Medical Gas Technician
Review By: Matthew Wachsmuth - ASSE 6030 Verifier
r
3314-9.7.21-VR Pg. 4 of 4
/fMedical 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 #: 3314
Facility: Distinctive Dentistry
Tested By: AC
Test Date: 9.7.21
Facility: ® New ❑ Existing
Type of Facility:
® Dental ❑ Medical ❑ Veterinary
❑ Lab ❑ Other:
Medical Gases ❑ NO N E
Oxygen Line: ® New ❑ Existing
Nitrous Oxide Line: ® New ❑ Existing ❑ NONE
Line Pressure: 52psi
Concentration: 97.8%
Line Pressure: 50 psi
Concentration: >99 %
Flow Test: >8 SCFH ( >_3.5 scfm ) ® Pass ❑ Fail
Flow Test: >8 SCFH ( >_3.5 scfm ) ® Pass ❑ Fail
Particulate Test: ® Pass ❑ Fail
Particulate Test: ® Pass ❑ Fail
Odor: ® Pass (None) ❑ Fail,
Odor: ® Pass (None) ❑ Fail,
Crossed Lines: ❑ Yes ® No
Outlet Brand: N/A
Quick Connect Style: DISS
Location of Outlets: Cabinets
Cylinder Storaqe ❑ NONE
Tank Room: ® New ❑ Existing
Location: ® Inside ❑ Remote
Door Labeled: ® Yes ❑ No
Individually Secured: ® Yes ❑ No
Cooling Sprinkler: ® Yes ❑ No
1 Hour Rated: ® Yes ❑ No
Separate from Mechanical Equipment: ® Yes ❑ No
Electrical Switches/Outlets 5' above floor: ® Yes ❑ No
Volume Connected or Stored: ® (3000 ft3 ❑ >3000 ft3
Number of Cylinders Connected: 1 OX x 1 N20
Ventilation: ® Natural ❑ N/A
Ventilation: ❑ Mechanical ® N/A
2 Openings 1' of Floor & Ceiling: ® Yes ❑ No ❑ N/A
Exhaust Fan Runs Continuously: ❑ Yes ❑ No ® N/A
Minimum 72 in' Free Area: ® Yes ❑ No ❑ N/A
Draws Air from within 1' of Floor: ❑ Yes ❑ No ® N/A
Vented directly to outside: ® Yes ❑ No ❑ N/A
Fan Connected to Essential Power: ❑ Yes ❑ No ® N/A
Manifold ❑ NONE
Manifold: ® New ❑ Existing
Piping Labeled: ® Yes ❑ No
Brand: Belmed
Flex Hoses < 5': ® Yes ❑ No / Rigid Copper ® Yes ❑ N/A
Model #: N/A
Check Valve DL of Regulator: ® Yes ❑ No
Serial #: N/A
Relief Valve 50% Above Norman Line Pres: ® Yes ❑ No
Alarm/ Warninq System ❑ NONE ❑ NOT REQUIRED
Alarm: ® New ❑ Existing ❑ None
Non -Cancellable Visual Alarm: ® Yes ❑ No
Brand: Belmed
Cancellable Audible Alarm: ® Yes ❑ No
Model #: N/A
HI / LO Line Pressure Alarm: ® Yes ❑ No
Serial #: N/A
Reserve In Use Alarm / Change Over: ® Yes ❑ No
3314-9.7.21 Pg.1 of 2
/fMedical 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)
=mergency Shutoff/Zone Valve ❑ NONE
Valve: ❑ New ❑ Existing ® None - Not Required Brand:
3 Part Valve: ❑ Yes ❑ No With Down Line Gauges: ❑ Yes ❑ No Sensor Location: ❑ UL ❑ DL
Labeled:
Dental Equipment ❑ Not Tested
Dental Air System: E New ❑ Existing ❑ NONE
Dental Vacuum System: E New ❑ Existing ❑ NONE
Brand: TechWest
Brand: TechWest
Model #: ACOR202
Model #: VPD252
Serial #: 11018
Serial #: VPD2-7337
Conf: ❑ Simplex ® Duplex ❑ Triplex ❑ Quad
Conf: ® Simplex ❑ Duplex ❑ Triplex ❑ Quad
Compressor Type: Oil Less
Pump Type: Oil. Less
Compressor On: 80 psi
Compressor Off: 110 psi
Vac Level: 15 "H9V
Horsepower: 1 hp.
Line Pressure: 105 psi
Particulate: ® Pass ❑ Fail
Drain: ® Sealed ❑ Open ® Floor ❑ Wall
Concentration: 20.7 %
Horsepower: 1.5 hp.
Flexible Connectors: Z Yes ❑ No
Receiver: Z Yes ❑ No
Drain: Z Manual ❑ Auto
Air / Water Separator: Z Yes ❑ No
Moisture Indicator: ® Yes ❑ No
Exhausted to Outside: ® Yes ❑ No
Dryer: ® Yes ❑ No Type: Desiccant
Location of Discharge: Roof
Intake: Z Outside ❑ Inside (other) ❑ Inside (same)
Piping: Z Hard Copper Z Schedule 40 PVC
Amalgam Separator
® New ❑ Existing
❑ Not Required ❑ None
Brand: Solmetex
Model #: NXT-HG5-001
Serial #: NXT69890
Comments:
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