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Thrive Kids Dentistry-3324-9.30.21(Medical Gas Services 918 S Horton St, Suite 917 Seattle, WA 98134 medsasservices.io (425) 894 5918 Dental Gas Line Verification Report Date: October 4th, 2021 Job Number: 3324 Contractor: Local Plumbing S Construction Date(s) and Time(s) of Testing: September 301h, 2021. - 0900 hrs. Facility: Thrive Kids Dentistry 10032 Edmonds Way, Suite #2 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. Most Medical Gas and Dental system components in area tested are in compliance with NFPA 99 (2012ed). Category 3, Dental. H. City of Edmonds: Permit # AFN 200203075001 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. 3324-9.30.21-VR Pg.1 of 4 Medical Gas Services 918 S Horton St, Suite 917 Seattle WA 98134 medgasservicesJo (425) 894 5918 II. Medical Gases A. Oxygen: 1. Static line pressure: 52 psig. 2. Oxygen concentration at outlet: 97.3% 3. Dynamic outlet free flow at outlet: >3.5 scfm B. Nitrous Oxide: 1. Static line pressure: 51 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: 100 psig. 2. Oxygen concentration at outlet: 21.3 % B. Dental Vacuum: 1. Static line vacuum: 10.5 "HgV. IV. Particulate Line Test: PASS V. Odor: PASS VI. Outlet: A. Outlet Style: DISS VII. Zone Valve: Yes VIII. Manifold / Alarm: A. Manifold: 1. Brand: Porter 2. Model Number: Vanguard 3. Serial Number: N/A B. Alarm: 1. Brand: Porter 2. Model Number: Vanguard 3. Serial Number: N/A 3324-9.30.21-VR Pg. 2 of 4 (Medical Gas Services 918 S Horton St, Suite 917 Seattle, WA 98134 medgasservices.io (425) 894 5918 IX. Dental Equipment: A. Dental Air: 1. System air components in compliance with NFPA 99(2012ed) 2. Brand: Adec 3. Model Number: SC5 4. Serial Number: 21HSC5-A00027 5. Configuration: Simplex 6. Horsepower: 1.5 hp 7. Intake: Inside(other) 8. Pump: Oil Less B. Dental Vacuum: 1. System vacuum components in compliance with NFPA 99(2012ed) 2. Brand: Adec 3. Model Number: DV5 4. Serial Number: 21HDV5-A00027 5. Configuration: Simplex 6. Horsepower: 2.3 hp 7. Vented too outside. C. Amalgam Separator: 1. Brand: Solmetex 2. Model Number: NXT-HG5-001 3. Serial Number: NXT69140 X. Cylinder Storage: A. Location: Remote B. Ventilation: Mechanical C. Cooling Sprinkler: Yes D. Door labeled: Yes E. 1 Hour Rated: Yes F. Cylinders Secured: Yes 3324-9.30.21-VR Pg. 3 of 4 Medical Gas Services 918 S Horton St, Sulte 917 Seattle WA 98134 medsasservices.io (425) 894 5918 XI. Brazier: Jose Villagrana A. Brazier Number: VILLA)*849PO B. Plumbing Contractor: Local Plumbing 6 Construction XII. Comments: A. Dental vacuum drain is sealed into wall 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 Waacchhsmuth - ASSE 6030 Verifier 3324-9.30.21-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 #: 3324 Facility: Thrive Kids Dentistry Tested By: AC Test Date: 9.30.21 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: 52 psi Concentration: 97.3% Line Pressure: 51 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: Wall 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: 2 OX x 2 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: Porter Flex Hoses < 5': ® Yes ❑ No / Rigid Copper ® Yes ❑ N/A Model #: Vanguard 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: Porter Cancellable Audible Alarm: ® Yes ❑ No Model #: Vanguard HI / LO Line Pressure Alarm: ® Yes ❑ No Serial #: N/A Reserve In Use Alarm / Change Over: ® Yes ❑ No 3324-9.30.21 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: Porter 3 Part Valve: E Yes ❑ No With Down Line Gauges: E Yes ❑ No Sensor Location: ❑ UL E DL Labeled: Emergency Shut Off Dental Equipment ❑ Not Tested Dental Air System: E New ❑ Existing ❑ NONE Dental Vacuum System: E New ❑ Existing ❑ NONE Brand: Adec Brand: Adec Model #: SC5 Model #: DV5 Serial #: 21HSC5-A00027 Serial #: 21HDV5-A00027 Conf: ® Simplex ❑ Duplex ❑ Triplex ❑ Quad Conf: ® Simplex ❑ Duplex ❑ Triplex ❑ Quad Compressor Type: Oil Less Pump Type: Oil Less Compressor On: 80 psi Compressor Off: 105 psi Vac Level: 10.5 "H9V Horsepower: 2.3 hp. Line Pressure: 100psi Particulate: ® Pass ❑ Fail Drain: ® Sealed ❑ Open ❑ Floor ® Wall Concentration: 21.3 % 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: ❑ Outside Z 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 #: NXT69140 Comments. - Dental vacuum drain sealed into wall 3324-9.30.21 Pg. 2 of 2