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Transform Weight Loss Med Gas Special InspectionTransform Weight Loss Remodel Verification October 2022 � P'. Kj !, P41F MedGas.com Verification completed by: Jim Brusse ASSE 6010, 6020, 6030, 6035, 6050 Transform Weight Loss 21911 7611 Ave. West Edmonds, WA 98026 V V o MedGas.com 6 October 2022 Transform Weight Loss Steve Lickar 21911 76th Ave West Edmonds, WA 98026 Re: Cat 1 annual medical gas inspection 1.0 Letter of verification Oxygen Medical Gas Services 4810 Pt. Fosdick Dr. #31 Gig Harbor, WA 98335 Office: (253) 303-0194 FAX: (253) 793-8686 A Medical Gas Verification of the source equipment, master alarm panels, valving hierarchy, labeling and identification, and patient care inlets and outlets has been completed. Criteria for this testing is based on the NFPA-99, 2012 edition, chapter 5, Standard for Health Care Facilities, the ASSE 6000 2018 edition, AIA, and CGA guidelines. This medical gas verification was found to be consistent with the requirements of the above -mentioned publications with noted exceptions. Ja es K. Brusse President Copies to: 6 October 2022 Date KLB (1) SL (1) The most complete medical gas company in the Pacific Northwest www.MedGas.com V V MedGas.com 2.0 Scope and Management Summary Oxygen Medical Gas Services 4810 Pt. Fosdick Dr. #31 Gig Harbor, WA 98335 Office: (253) 303-0194 FAX: (253) 793-8686 The scope of this report is a medical gas inspection to a category 1 facility as defined by NFPA-99, 2012 edition. Medical Gases, Support Gases, vacuum involved were oxygen and surgical vacuum. The Medical Gas System inspection tests were performed as outlined in the NFPA-99, 2012 edition. 1. Bulk/Manifold location, function, and alarm reporting 2. Pump/compressor location, performance, and alarm reporting 3. Master/area alarm location, function, and labeling 4. Valve performance, location, and labeling 5. Inlet/Outlet latch, flow, and concentration 3.0 Management Summary The medical gas systems tested above are in compliance with the NFPA-99, 2012 edition. Tests/Verification performed: 3.1 Vacuum pumps The mechanical room meets NFPA99 requirements except for any noted deficiencies. 1. Primary to lag cycle works with Lag in use alarm sent to master alarm panels 2. Run timers work as designed 3. Overall condition of vacuum pumps is: Fair 3.2 Medical gas manifolds — 02 The manifold room meets NFPA99 requirements except for any noted deficiencies. 4. Switch from left bank to right and right bank to left with local and master alarm reporting 5. All redundancies and labeling are correct 6. Vent lines brazed and labeled 3.3 Master Alarm panels The master alarm panels are properly located 7. Each alarm is labeled correctly 8. Individual alarm locations on each master alarm panel are identical 9. Audible and visual functions tested 3.4 Valves The valves were inspected for location, type, labeling, and security 10. Source/main valves are secure and properly labeled 11. Zone valves are properly located and labeled The most complete medical gas company in the Pacific Northwest www.MedGas.com V V MedGas.com 3.5 Inlets and Outlets The inlets and outlets in each patient care area were tested 12. Latches function as designed 13. Flow rates meet SUM guidelines for the area served 14. Concentration of gas meets NFPA99 standards — See below Oxygen Medical Gas Services 4810 Pt. Fosdick Dr. #31 Gig Harbor, WA 98335 Office: (253) 303-0194 FAX: (253) 793-8686 3.6 Medical Gas Concentration Testing (5.1.12.3.11) The specific tasks performed to inspect the medical gas concentrations are analyzed to meet or exceed the following table: (Table 5.1.12.3.11 Gas Concentrations) Oxygen >_99% oxygen Nitrous Oxide >_99% nitrous oxide Nitrogen <_1 % oxygen Medical air 19.5%-23.5% oxygen Other gases ±1 %, unless otherwise specified 4.0 Quality Control The Quality control program is designed to assure that measurements made in this report are correct and accurate. To this end, the following equipment was used in testing. Function Make Model Serial # Calibration frequency Calibration due Oxygen MaxTec FJ73599008 Dail N/A Flow Dwyer X100 N/A 12 months 4/08/2023 Pressure Dwyer DPG-107 1 P18322C16AB-8 12 months 4/08/2023 Purity Enmet Matrix + 125-0188 12 months 3/17/2023 Scale 1/10,000g Sartorius 32805552 Daily N/A 5.0 Personnel The following personnel completed the medical gas Verification Name Title Credentials Ex iration date Covid vaccination Jim Brusse Lead ASSE 6030 8/2024 YES John Schauble Lead ASSE 6040 7/2024 YES 6.0 Outlets/Inlets tested The following is the outlet and inlet tested/not tested counts Oxygen Medical Air Vacuum Nitrous Oxide WAGD Nitrogen Carbon Dioxide Tested 165 97 213 8 3 3 3 Not Tested* 22 14 30 0 0 0 0 Total 187 121 243 8 3 3 3 *Not tested is an estimated count of outlets and inlets The most complete medical gas company in the Pacific Northwest www.MedGas.com y; MedGas.com Transform Weight Loss. Edmonds, WA 6 October 2022 MEDICAL GAS & VACUUM REPORT KEY FACILITY CONTACT: Steve Lickar SLickarC@TransformWeightLoss.com 206-914-1034 ADDRESS: 21911 76th Ave West. Edmonds, WA 98026 Oxygen Medical Gas Services certifies that all items listed within report have been inspected and, were in compliance with NFPA 99C, AIA and CGA guidelines on the date tested, except for those items so indicated in this test report. ITEMS INSPECTED SYSTEM PATIENT TERMINALS & FLEXIBLE CONNECTORS O, A, V, NO, C, N, W, I SOURCE EQUIPMENT O, A, V, NO, C, N, W, I MEDICAL ISOLATION VALVES O, A, V, NO, C, N, W, I MASTER ALARMS O, A, V, NO, C, N, W, I AREA ALARMS O, A, V, NO, C, N, W, I CROSS CONNECTIONS O, A, V, NO, C, N, W, I CONCENTRATION O, A, NO, C PURITY & PARTICULATE * NOT IN SCOPE OF ANNUAL INSPECTIONS • •' CODE M0&ND A= MEDICAL AIR NO =NITROUS OXID CARBON• N =NITROGEN W =WASTE ANESTHESIA GAS I =INSTRUMENT AIR The medical gas systems that are represented in this report have been evaluated in accordance with NFPA99 by Oxygen Medical Gas Services personnel who are familiar and credentialed to perform the duties outlined in the ASSE 6000 and NFPA99 2012 edition. The systems have been found to meet or exceed the requirements of the NFPA99 except where noted in the final inspection report. IF YOUR FACILITY, OR CERTAIN AREAS OF YOUR FACILITY, IS NOT IN STRICT COMPLIANCE WITH THE NFPA99, THE AUTHORITY HAVING JURISDICTION SHOULD DECIDE WHETHER TO CORRECT THE DEFICIENCIES, UPGRADE THE AREA TO MEET THE NFPA99 2012, OR REMAIN THE SAME. SIGNATURE: x DATE: 6 October 2022 OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. #31 Gig Harbor, WA 98335 Office (253) 303-0194 Fax (253) 793-8686 email: Jim@OXyxenMedGas.com www.MedGas.com VY MedGas.com Transform Weight Loss SUMMARY REPORT OBSERVATIONS FOR UPGRADES — NOT A RECOMMENDATION 6 October 2022 Location Problem/Deficiency Suggestion Reference Corrected by &date Bottle room Mechanical ventilation duct has two openings Blank off the upper opening 9.3.7.5.3.3 Bottle room Master alarm panel not located in the office or workspace of the responsible person Relocate master alarm panel to upstairs office 5.1.9.2.1 (1) 4810 Pt. Fosdick Dr. NW #31 *Gig Harbor, WA 98335 • PH (253)303-0194 • FAX (253)793-8686 www.MedGas.com V \��V MedGas.com Transform Weight Loss. Edmonds, WA 6 October 2022 Line Purity Sample Form Facility: Transform Weight Loss 21911 76t" Ave West Edmonds, WA 98026 Installation of new oxygen line from the manifold in the bottle room located in the basement parking garage to the new facility on the first floor. Installer: ACCO ES Donovan DeWitt WA L&I ASSE 6010 DEWITDM947D7 Expires 30 April 2024 Verifiers pressure test: Start at 11:25am with 50psi End at 11:35am with 50psi PASS Piping Purity: Enmet Matrix analyzer S/N 125-0188 N2NF Baseline sample: Supplier: Central Welding N2NF Cyl# ENKE1133 Batch# T0818201 Dew Point -35°F Non -Methane Hydrocarbons 0.1ppm Halogenated hydrocarbons Oppm 02 line sample: From 02 source valve to the 02 wall outlet in bay 6 Dew Point -330F Non -Methane Hydrocarbons 0.2ppm, result <5ppm PASS Halogenated hydrocarbons Oppm, result <5ppm PASS Piping Particulate: EMD Millipore pre weight .0814 Post weight .0821 PASS Signature: U�2l�dd� Date:6 October 2022 All testing in this report completed by above signed ASSE 6030 per NFPA-99 2012 standards OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253)303-0194 Fax (253)793-8686 email: lim@OxygenMedGas.com www.MedGas.com VY; V �Jf�1L� MedGas.com Transform Weight Loss. Edmonds, WA 6 October 2022 MANIFOLD ROOM SOURCE LOCATION EVALUATION Location of manifold room: SW corner of the basement parking garage Manifolds located in room: X❑ Oxygen ❑ Medical Air ❑ Nitrous Oxide ❑ Nitrogen ❑ Carbon Dioxide ❑ Instrument Air Yes No N/A ❑X ❑ ❑ 1. Is the location used ONLY for storage of non-flammable gases? [5.1.3.2.3] 0 ❑ ❑ 2. Is the location kept free of flammable materials, flammable gas cylinders, and flammable liquid containers? [5.1.3.2.4] 0 ❑ ❑ 3. Is the location separate from mechanical equipment (i.e., air compressors, vacuum pumps, diesel fuel pumps)? .5.1.3.3.1.41 0 ❑ ❑ 4. Is location access restricted to authorized personnel only and adequately secured against tampering? 0 ❑ ❑ 5. Is the location free of open electrical contacts or transformers? [5.1.3.3.1.6 (4)] 0 ❑ ❑ 6. Are electrical wall fixtures at least 5 ft. above floor or protected? _�.1.3.3.2 (10)1 0 ❑ ❑ 7. Is the location protected from sources of heat exceeding 130°F? [5.1.3.3.1.7] 0 ❑ ❑ 8. Are cylinders protected against accumulation of ice and snow or continuous exposure to direct rays of the sun? 0 ❑ ❑ 9. Are indoor locations constructed of materials with a minimum of 1-hour fire resistance rating? 15.1.3.3.2 (4)] ❑ ❑X ❑ 10. Does the manifold room employ natural ventilation? [5.1.3.5.6.1(4)] Yes No ❑ ❑ a) Are there a minimum of two openings on an exterior wall? ❑ ❑ b) Are the openings located a foot from the floor and a foot from the ceiling? ❑ ❑ c) Are the openings a minimum of 72 in sq? OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253)303-0194 Fax (253)793-8686 email: Jim@OxygenMedGas.com www.MedGas.com VY; V �Jf�1L� MedGas.com Transform Weight Loss. Edmonds, WA 6 October 2022 MANIFOLD ROOM CONTINUED Yes No N/A ® ❑ ❑ 11. Is the location vented outside by means of a dedicated mechanical ventilation system for indoor medical gas systems that don't meet natural ventilation requirements? Yes No X❑ X❑ a) Does the vent draw air from within one foot of the floor? [9.3.7.5.3.3] X❑ ❑ b) Is the exhaust fan connected to essential power? [9.3.7.5.3.4] ❑X ❑ ❑ 12. Is the appropriate door sign based on medical gasses permanently posted on the door? 5.1.3.1.8 or 5.1.3.1.9] 0 ❑ ❑ 13. Are the cylinders secured with racks, chains, or other fastenings per OSHA standards? 0 ❑ ❑ 14. Are the manifolds, valves, and piping protected against physical damage from movement of cylinders and equipment? 15.1.3.3.2 (1)] 0 ❑ ❑ 15. Do relief valves vent to the outside, except for medical air systems less than 3000 cu ft? .1.3.5.b.1 (4)J Yes No ❑X ❑ a) Is the relief valve discharge turned down and screened to prevent entry of rain, snow, or vermin? X❑ ❑ b) Is the relief valve vent piping ASTM B-819 medical gas tube? [5.1.3.5.6.2] X❑ ❑ c) Are joints in relief valve vent piping brazed or Lokring? [5.1.3.5.6.2] X❑ ❑ d) Is relief valve vent piping labeled to distinguish from medical gas pipelines? [5.1.3.5.6.4] fnMMFNTC 11a. Upper ventilation opening needs to be blocked off OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253)303-0194 Fax (253)793-8686 email: Jim@OxygenMedGas.com www.MedGas.com V� V MedGas.com Transform Weight Loss. Edmonds, WA Oxygen HP x HP Manifold SOURCE EVALUATION DATA 6 October 2022 Location of manifold: SW corner of the parking garage Area Served: Transform weight Loss Manifold Manufacturer: Amico Model Number: M4D-DL-HH-U-OXY Serial Number: 20220705-0014 # Of cylinders Left Bank: 3 # Of cylinders Right Bank: 3 Main line pressure: 52 PSI Gauge range: 0-100 PSI Left bank pressure/status: 2,173 PSI — In Use Gauge range: Digital Right bank pressure/status: 2,140 PSI - Ready Gauge range: Digital Yes No N/A ❑X ❑ ❑ 1. Are final line regulators duplexed with isolation valves upstream of each regulator and shutoff valves or check valves downstream? [5.1.3.5.5.1(1-2)] Yes No X❑ ❑ a) Is the manifold supplied by a recognized manufacturer? r5.1.3.5.11 ❑X ❑ ❑ Are gauges downstream of each regulator present? i5.1.3.5.5.1 (3)] 0 ❑ ❑ Is a relief valve set at 50% above normal line pressure, located between each regulator and the source valve? t5.1.3.5.6.3 (1-2)] Yes No X❑ ❑ a) Do relief valves vent to the outside, except for medical air systems less than 3000 cu ft? [5.1.3.5.6.1 (4)] X❑ ❑ b) Is the relief valve discharge turned down and screened to prevent entry of rain, snow, or vermin? X❑ ❑ c) Is the relief valve vent piping ASTM B-819 medical gas tube? [5.1.3.5.6.2] X❑ ❑ d) Are joints in relief valve vent piping brazed or Lokring? [5.1.3.5.6.2] X❑ ❑ e) Is relief valve vent piping labeled to distinguish from medical gas pipelines? [5.1.3.5.6.4] ❑X ❑ ❑ 3. Does each cylinder bank contain at least an average days' (24 hours) supply with a minimum of 2 cylinders? 5.1.3.5.10.4 (1)J 0 ❑ ❑ 4. Is manifold changeover from primary to secondary automatic? [5.1.3.5.10.5] OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253)303-0194 Fax (253)793-8686 email: Jim@OxygenMedGas.com www.MedGas.com V� V MedGas.com NEW - Yes No N/A ❑X ❑ ❑ Transform Weight Loss. Edmonds, WA Oxygen HP x HP Continued 6 October 2022 5. Is there an actuating switch present to indicate when changeover occurs from Primary to Secondary? 15.1.3.5.10.6] Yes No X❑ ❑ a) Is there a visual indicating local signal present? [5.1.3.5.10.6] X❑ ❑ b) Is it wired to the master alarm? © ❑ ❑ 6. Do the header bars contain required pigtails with check valves? [5.1.3.5.9 (7)] ❑X ❑ ❑ 7. Is manifold supplied/built by a recognized medical equipment supplier/manufacturer? ❑X ❑ ❑ 8. Are operating and maintenance instructions available? 0 ❑ ❑ 9. Does a periodic inspection and maintenance program exist for source equipment and alarms? [5.1.14.2.2.2] 0 ❑ ❑ 10. Is there a high/low line pressure switch on the main line? [5.1.9.2.4 (7)] Yes No ❑X ❑ a) Is it wired to the master alarm? X❑ ❑ b) Is the switch located on the patient side of the main valve, or source valve if there is no main valve? X❑ ❑ c) Is the switch connected with a gas specific demand check fitting? '.1.8.2.3] X❑ ❑ d) Is there a gauge installed next to the switch after the source/mainline shutoff valve? 15.1.8.2.2 (1 Location of switch: ❑X ❑ ❑ 11. Is the source valve installed in the immediate vicinity of the source equipment? 5.1.4.4] Yes No X❑ ❑ a) Is it labeled? [5.1.11.2] ❑X ❑ ❑ 12. Is the manifold equipment free of leakage? COMMENTS: Added a Source Valve Tag OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253)303-0194 Fax (253)793-8686 email: Jim@OxygenMedGas.com www.MedGas.com V� V MedGas.com Transform Weight Loss. Edmonds, WA Surgical Vacuum SOURCE EVALUATION DATA 2012 NFPA-99 6 October 2022 LOCATION OF VACUUM PUMP: MECHANICAL ROOM PAST BOTTLE ROOM AREA SERVED: FACILITY UNIT MANUFACTURER: EMSE TECH SUPPORT PHONE: 1 800-962-5385 UNIT MODEL NUMBER: 1DRR2T80 SERIAL NUMBER: 29840608 PUMP MANUFACTURER: HP: 3 VOLTAGE: 460 VACUUM PUMP DATA MODEL# SERIAL# 2021 HOURS 2022 HOURS UNIT 1 4107655514 U181000101 14983 UNIT 2 4107655514 U180200054 10218 U NIT 3 U NIT 4 THE VACUUM MAIN LINE PRESSURE IS: 21.7"HG GAUGE RANGE IS: 0-30HG THE LEAD PUMP IS ON AT 20.5" HG AND OFF AT 24" HG LAG IS ON AT 19" HG AND OFF AT 22" HG TEMPERATURES AMBIENT OIL SITE GLASS OIL FILTER PUMP EXHAUST UNIT 1 NEW START UP UNIT 2 U NIT 3 U NIT 4 Yes No N/A ❑X ❑ ❑ 1. Is the data on this sheet for the following source(s): LEAD & LAG? 0 ❑ ❑ 2. Is the entire area Facility served by this source? 0 ❑ ❑ 3. Is the room adequately vented to prevent accumulation of heat per manufacturers' recommendation? 0 ❑ ❑ 4. Are there two or more pumps? 0 ❑ ❑ 5. Does each pump have a check valve to prevent backflow through off -cycle units? 0 ❑ ❑ 6. Does each pump have isolation valves on intake piping? 0 ❑ ❑ 7. Does each pump have isolation valves (or equivalent) on exhaust piping? NOTE: If the answer is no, a tube cap can be used when pumps are removed from service. 0 ❑ ❑ 8. Is there sufficient flexible couplings installed in the piping to and from the equipment? 0 ❑ ❑ 9. Is there a receiver? Yes No ❑X ❑ a) Does the receiver have an ASME data plate? ❑X ❑ b) Does the receiver have sufficient manual drain? ❑X ❑ c) Is the receiver valved to allow draining or servicing without interrupting the Vacuum system? OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253) 303-0194 Fax (253) 793-8686 email: Jim@OxygenMedGas.com www.MedGas.com V� V MedGas.com Transform Weight Loss. Edmonds, WA VACUUM CONTINUED 6 October 2022 Yes No N/A © ❑ ❑ 10. Is system capable of automatically activating additional units to maintain vacuum? Yes No ❑X ❑ a) Is there a local audible / visual signal when lag pump is in operation? ❑X ❑ b) Does the signal latch, requiring manual reset? ❑X ❑ c) Is it wired to master alarm panels? ❑X ❑ ❑ 11. Is there automatic pump alternation to provide for even wear? 0 ❑ ❑ 12. Are there dedicated disconnect switches, motor starting devices, and overload protection for each pump? 0 ❑ ❑ 13. Is power supplied by the equipment branch of the essential electrical system? 14. Vacuum Exhaust: Yes No ❑X ❑ a) Is the exhaust outdoors and at least 10 ft. from any door, window, air intake, or other opening in the building? ❑X ❑ b) Is the exhaust discharge turned down and screened or otherwise protected from vermin, debris, or precipitation? ❑X ❑ c) Is there a trapped drip leg with valved drain on the exhaust line to discharge condensate or oil? ❑X ❑ d) Is the exhaust piping considered to be of proper size to minimize back pressure? Exhaust Location: Roof ❑X ❑ ❑ 15. Is Vacuum distribution piping hard -drawn copper or stainless steel pipe? 0 ❑ ❑ 16. Is the source piping appropriately labeled for Vacuum? Yes No ❑X ❑ Is the label background color white? ❑X ❑ ❑ 17. Is the source valve in the immediate vicinity of the source equipment? Yes No ❑X ❑ Is the source valve labeled? ❑X ❑ ❑ 18. Is there a line vacuum low switch wired to the master alarm panels? Yes No ❑X ❑ a) Is the switch located on the patient side of the main valve, or source valve if there is no main valve? ❑X ❑ b) Is the switch connected with a demand check fitting? ❑X ❑ c) Is the demand check fitting gas specific? ❑X ❑ d) Is there a gauge installed next to the switch after source/mainline shutoff valve? Location of switch: Just downstream of Source Valve COMMENTS: Vacuum will need a 5,000 service. Added a source valve tag OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253) 303-0194 Fax (253) 793-8686 email: Jim@OXygenMedGas.com www.MedGas.com 1YOf \�V V V MedGas.com Transform Weight Loss. Edmonds, WA 6 October 2022 MASTER ALARM PANEL #1 LOCATION: NURSE STATION POWER LIGHT FUNCTIONAL: YES MANUFACTURER: AMICO MODEL: ALERT / AREA COMBO ALARM TESTED SENSOR LOCATION SET POINTS VISUAL INDICATOR AUDIBLE INDICATOR LABEL COMMENTS OXYGEN RESERVEIN USE PASS PASS PASS PASS PASS LINE PRESSURE HIGH PASS PASS PASS PASS PASS LINE PRESSURE LOW PASS PASS PASS PASS PASS VACUUM LINE PRESSURE LOW PASS PASS PASS PASS PASS LAG PUMP IN USE PASS PASS PASS PASS PASS MASTER ALARM PANEL #1 LOCATION: BOTTLE ROOM POWER LIGHT FUNCTIONAL: YES MANUFACTURER: AMICO MODEL: ALERT DIGITAL ALARM TESTED SENSOR LOCATION SET POINTS VISUAL INDICATOR AUDIBLE INDICATOR LABEL COMMENTS OXYGEN RESERVE IN USE PASS PASS PASS PASS PASS SEE NOTES BELOW LINE PRESSURE HIGH PASS PASS PASS PASS PASS LINE PRESSURE LOW PASS PASS PASS PASS PASS VACUUM LINE PRESSURE LOW PASS PASS PASS PASS PASS LAG PUMP IN USE PASS PASS PASS PASS PASS COMMENTS: 02 MAIN LINE Pressure set points tested at 20% above and 20% below designated operating pressures Vac main line set point tested at 12"Hg NFPA99 2012 states two master alarm panels are required for a category 1 facility. One master alarm panel shall be located in an area of continued observation and the other shall be in the work area of the individual responsible for the medical gases. The master alarm panel at the nurse station meets the criteria of continued observation. In my opinion, the master alarm panel in the bottle room does not meet the requirement to be in the work area of the person responsible for the medical gas. suggest relocating the master alarm panel to the office in the SE corner of the suite. OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253) 303-0194 Fax (253) 793-8686 email:--„JxygenMeclGas.com www.MedGas.com '4v V yV �1 XdGasxom Transform Weight Loss. Edmonds, WA 6 October 2022 MEDICAL GAS VALVES - SERVICE NITROUS CARBON OXYGEN MEDICAL AIR VACUUM OXIDE DIOXIDE VALVE TYPE SOURCE SOURCE BOTTLE BOTTLE LOCATION ROOM ROOM AREA OF FACILITY FACILITY CONTROL LEAK TEST PASS PASS LABELING PASS PASS ACCESS PASS PASS NFPA YES YES COMPLIANT COMMENTS ADDED VALVE ADDED VALVE TAG TAG COMMENTS: OXYGEN MEDICAL GAS SERVICES 4810 Pt. Fosdick Dr. NW #31 Gig Harbor, WA 98335 Office (253) 303-0194 Fax (253) 793-8686 email: Jim@OXygenMedGas.com www.MedGas.com Oxygen Medical Gas Systems Gig Harbor Washington Facility: Transform Weight Loss Date: 6 October 2022 Bldg: main Verifier: Jim Brusse Floor: 1st Unit: OR Suite Zone Valve Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Gauge reading 54 PSI 23"Hg Location: Outside OR-1 Pipe size 1/2" 3/4" Rooms Served: OR-1 Labeling Pass Pass Notes: N20 is out of service Leak Test Pass Pass Area Alarm Panel Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Switch location: Downstream of ZVB Pressure reading 52 PSI 24"Hg Location: Outside OR-1 Audible Indicator ± 20% Pass Pass Rooms Monitored: OR-1 Visual Indicator ± 20% Pass Pass Notes: Labeling Pass Pass Outlets/Inlets Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Pressure 54 PSI 25"Hg Outlet style: DISS Flow Rate: > 6.0 SCFM Pass Pass Notes: All outlets and inlets are on the ceiling Concentration 100% 02 N/A Room Number Qty Qty Qty Qty Qty Test Result: Observations: Room OR-1 2 2 Pass Total # outlets/inlets 2 0 2 0 1 0 All Tests conform to the NFPA99 2012 edition Verifier Signature: Date: 6 October 2022 Oxygen Medical Gas Systems Gig Harbor Washington Facility: Transform Weight Loss Date: 6 October 2022 Bldg: Main Verifier: Jim Brusse Floor: 1st Unit: Procedure Zone Valve Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Gauge reading 54 PSI 26"Hg Location: Outside Procedure 1 Pipe size 1/2" 3/4" Rooms Served: Procedure 1 Labeling Pass Pass Notes: Leak Test Pass Pass Outlets/Inlets Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Pressure 54 PSI 22"Hg Outlet style: Ohmeda Flow Rate: > 3.5 SCFM Pass Pass Notes: Concentration 100% 02 N/A Room Number Qty Qty Qty Qty Qty Test Result: Observations: Procedure 1 1 2 Pass Total #outlets/inlets 1 0 2 0 0 0 All Tests conform to the NFPA99 2012 edition Verifier Signature: /�• �� Date: 6 October 2022 Oxygen Medical Gas Systems Gig Harbor Washington Facility: Transform Weight Loss Date: 6 October 2022 Bldg: main Verifier: Jim Brusse Floor: 1st Unit: Recovery Zone Valve Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Gauge reading 56 PSI 25"Hg Location: Hallway to lobby Pipe size 1/2" 3/4" Rooms Served: Recovery bays 1-6 Labeling Pass Pass Notes: Leak Test Pass Pass Area Alarm Panel Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Switch location: Downstream of ZVB Pressure reading 54 PSI 24"Hg Location: Nurses Desk Audible Indicator ± 20% Pass Pass Rooms Monitored: Recovery Bays 1-6 Visual Indicator ± 20% Pass Pass Notes: N20 is out of Service Labeling Pass Pass Outlets/Inlets Oxygen Med Air Vacuum N20 CO2 Manufacturer: Amico Pressure 54 PSI 25"Hg Outlet style: Ohmeda Flow Rate: > 3.5 SCFM Pass Pass Notes: Concentration 100% 02 N/A Room Number Qty Qty Qty Qty • Qty Test Result: Observations: Recovery Bay 1 1 1 Pass Recovery Bay 2 1 1 Pass Recovery Bay 3 1 1 Pass Recovery Bay 4 1 1 Pass Recovery Bay 5 1 1 Pass Recovery Bay 6 1 1 Pass Total # outlets/inlets 6 0 6 0 0 0 All Tests conform to the NFPA99 2012 edition Verifier Signature: /�. U12ua�� Date: 6 October 2022