Med Gas Verification.pdfMedical Gas Services, L,LC
6355 NE 1518t Street
Kenmore, WA 98028
425.877-9623
i
Verification hie.' oi
Date: March 6, 2015
Job Number: 900681
Contractor: Andgar Corporation
Date(s) / Time(s) of Testing: March 5, 2015 / 0900
Facility: 5th Ave animal Hospital
310 5th Ave S,
Edmonds, WA 98020
Scope of Work: New veterinary oxygen system,
Our firm certifies that the verifier named in the report is properly trained and certified to perform the activities
required, All test and measurement equipment is properly calibrated and maintained. As a representative of Airgas
USA, 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 oxygen is in compliance with portions of NFPA 99(2012ed): Level 3, Veterinary System
S. No crossed lines were found in medical oxygen in tested area on the day of testing.
C. Medical oxygen meets minimum concentration,
D. Medical oxygen meets minimum flow and is at normal pressure.
E. Veterinary oxygen system components in area tested are in compliance with portions of
NFPA 99(2012ed): (See Comments and Recommendations)
F. Purge Gas #058TUA4029-A (AL)
G. Initial Pressure Test: PASS
City of Edmonds: Permit # BLD20140-400
H. Attachments: Work sheets
5thAveAnimal Hospital -3.5.15 -VR -Veterinary (2012ed) Pg. 1 of 3
Medical G Services, N N C
83S5NE161mStreet
Kenmore, VVA88028
426'877~9823
U. Medical Gas:
A. Oxygen:
1. Static Line Pressure: 52 psig.
2. Dynamic Outlet Free Flow: >3.5aofm.
3. Concentration of oxygen at outlet: 99,0%
Ui Vacuum: NnMedical/Surgical System
A. Veterinary Vacuum:
1. Static Line Vacuum: "HoV
2. Dynamic Outlet Free Flow: >3.0 scfm.
Ki Particulate Line Test: PASS
V. Odor: NONE
VI. Outlet / Inlets Brand: Tri Tech Medical
1. Quick Connect Style: Ohio
VII. Zone Valve: Tri Tech Medical
V1U. Manifold and Alarm:
A. Manifold:
1, Brand: Superior Products, LLC
2. Model Numbe[GMA4M1O
3. Serial Number: NA
D. Alarm:
1. Brand: Superior Products, LLC
2. Model Number: GMA-KAK
3. Serial Number: NA
0i Cylinder
A. Location: Remote
B. Ventilation: Mechanical
C. Sprinkler: Yes
D. Door Labeled per NFPA:Yes
E. 1Hour Rated: PASS per NFRA
F. Cylinders Secured: PASS per NFPA
X. Brazier: Roger LJager
A. Brazier NUmber:JAGERRL92OR
B. Plumbing Contractor: Andgar Corporation
5thAv*Animal Mo8pital-3.5154/R4/8tehnary (2U12ed) Pg. 2of3
Medical Gas Services, Ll ............ C
6355 NE 151st Street
Kenmore, WA 98028
425.877-9623
X11. Comments:
A. None
XIII. Recommendations:
A. None
Tested By: Harry Pomeranz ® ASE 6030 Verifier
A4. . . . ...........
5thAveAn im al Hospital-3.5.15-VR-Veteri nary (2012ed) Pg. 3 of 3
Medical Gas Serv�� ices, L.W
A'level 3 Verification Check List
Facility: 51h Ave Animal Hospital Tested By: HP FTest Date: 3/5/15
Facility: E New 0 Existing I Type of Facility- El Dental E] Medical E Veterinary El Lab El Other:
xxnmi.-nu,'_naac F-1mONr
-'-------
Oxygen Line: N New F] Existing
Nitrous Oxide Line: E] New F-1 Existing E NONE
Line Pressure: 52 psi
Concentration: >99 %
Line Pressure: psi
c
Flow Test: SCFH -a3.5 scfm ) N Pass El Fail
Flow Test: SCFH ( �:3.5 scfm ) E] Pass E] Fail
Particulate Test: M Pass n Fail
Particulate Test: El Pass [:]Fail
Odor: N Pass (None) El Fail,
Odor: E] Pass (None) 0 Fail,
Crossed Lines: E] Yes 0 No
Outlet Brand: Tri Tech
Quick Connect Style: Ohio
Location of Outlets: walls
F-1 hinkic
Tank Room: 0 New EJ Existing
Location: El Inside N Remote
Door Labeled: El Yes E] No
Individually Secured: E Yes 0 No
Cooling Sprinkler: N Yes El No
1 Hour Rated: N Yes 0 No
Separate from Mechanical Equipment: E Yes [] No
Electrical Sw1itches/Outlets 5' above floor: E] Yes [] No
Volume Connected or Stored: N <3000 ft' E] >3000 f?
Number of Cylinders Connected: OX 2 x N20 0
Ventilation: El Natural 0 N/A
Ventilation: 0 Mechanical 0 N/A
2 Openings Il'of Floor & Ceiling: 0 Yes El No N N/A
Exhaust Fan Runs Continuously: N Yes [:] No E] N/A
Minimum 72 in 2 Free Area: [:] Yes E] No 0 N/A
Draws Air from within I' of Floor: 0 Yes N No El N/A
Vented to Exit Access Corridor: Ej Yes E] No N N/A
Fan Connected to Essential Power: 0 Yes E] No N N/A
-
'~-----'Manifold: E New E] Existing
Piping Labeled: 0 Yes EJ No
Brand: Superior Products, LLC
Flex Hoses < 5': E Yes E] No / Rigid Copper E Yes E] N/A
Model #: Mighty Max GMA-M10
Check Valve DIL of Regulator: E Yes E] No
Serial #: NA
Relief Valve 50% Above Norman Line psi: [E Yes E] No
Medical Gas Sevvices, LLC
1:mergency Shutoff / Zone Valve [] NONE
Valve: Z New R Existing R None — Not Required ri Tech
3 Part Valve: M Yes [] No With Down Line Gauges: M Yes El No Sensor Location: F -I UL F] DL NA
Labeled: NA
___