Report 10/05/2004 22:50 FAX Z016/018
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914eicas Certified, LLC
911edicaf gas Professionarst
Medical Gas Verification Report
"Dr. Brandon Dentistry for Children & Teens
11565 SW Durham Rd., Suite 100
Tigard, OR 97224
Date of Certification,: October 5, 2004
Date of this Report: October 6, 2004
Certification provided by:
MedGas Certified, LLC
220 St James Ct.
Longview, WA 98632
360 - 430 -2151
360 - 636 -4131 (fax)
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Medan Ce filed, LLO
Medical Gas Pr fessierted$
Medical( Pipeline Verification
The Medical Gas Certification Specialist Glenn Tsuda tested the Medical Pipeline
System indicated by this report in accordance with the 1999 edition of NFPA 99 and
other applicable codes or agencies. The testing criteria were used as a base line for
determining the performance of the separate components that make up this "Level
3 Dental Facility." The tests performed on this system were found to be within test
specifications unless otherwise noted on the Discrepancies or separate pipeline
system component forms. The additional documentation contains the results, dates
and locations of the tests performed.
The testing of this system may include all or part of the tests offered by MedGas
Certified, LLC. Only the tests indicated by the report forms were performed on the
dates indicated. The results of the tests reported represent the findings of MedGas
Certified on the dates and locations indicated by the report forms only.
Per NFPA99C 1999 Edition:
The National Fire Protection Association does not approve, inspect, or certify any
installations, procedures, equipment, or materials; nor does It approve or evaluate
testing laboratories. In determining the acceptability of installation, procedures,
equipment, or materials the authority having jurisdiction may base acceptance on
compliance with NFPA or other appropriate standards, In the absence of such
standard, said authority may require evidence of proper installation, procedure or
use. The authority having jurisdiction may also refer to the listing of labeling
practices of an organization that is concerned with product evaluation and is thus in
a position to determine compliance with appropriate standards for the current
production of listed items.
Per NFPA99C 1999 Edition:
The phrase 'authority having jurisdiction" is used in NFPA documents in a broad
manner, since jurisdictions and approval agencies vary, as do their responsibilities,
Where public safety is primary, the authority having jurisdiction may be a federal,
state, local, or other regional department or individual such as a fire thief; fire
marshal; chief of a fire prevention bureau, labor department, or health department;
building official; electrical inspector; or others having statutory authority, For
insurance purposes, an insurance inspection department, rating bureau, or other
insurance company representative may be the authority having jurisdiction, In many
circumstances, the property owner or his or her designated agent assumes the role
of the authority having jurisdiction; at government installations, the commanding
officer or departmental official may be the authority having jurisdiction.
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Med Gas Certified, ILO
medical Gas Professionals
Medical Gas Verification Report Summary
Note: This Verification Report Summary is incomplete unless/until accompanied by
the following documents:
1. Medical Gas and Vacuum Pipeline System Verification "Oxygen Manifold"
checklist dated 10/05/04 and signed by Glenn Tsuda, Medical Gas
Verification Specialist.
2. Medical Gas and Vacuum Pipeline System Verification "Warning Systems for
Gases - Oxygen" checklist dated 10/05/04 and signed by Glenn Tsuda,
Medical Gas Verification Specialist.
3, Medical Gas and Vacuum Pipeline System Verification Nitrous Oxide
Manifold" checklist dated 10/05/04 and signed by Glenn Tsuda, Medical Gas
Verification Specialist.
4. Medical Gas and Vacuum Pipeline System Verification "Warning Systems for
Gases — Nitrous Oxide" checklist dated 10/05/04 and signed by Glenn
Tsuda, Medical Gas Verification Specialist
5, Medical Gas and Vacuum Pipeline System Verification "Medical Air
Compressor" checklist dated 10/05/04 and signed by Glenn Tsuda, Medical
Gas Verification Specialist.
6, Medical Gas and Vacuum Pipeline System Verification "Medical Vacuum
Pump" checklist dated 10/05/04 and signed by Glenn Tsuda, Medical Gas
Verification Specialist_
7. Medical Gas and Vacuum Pipeline System Verification "System Verification
and Final Test" checklist dated 10/05/04 and signed by Glenn Tsuda,
Medical Gas Verification Specialist.
S. Medical Gas and Vacuum Pipeline System Verification "Outlet/inlet" checklist
dated 10/05/04 and signed by Glenn Tsuda, Medical Gas Verification
Specialist.
9. Medical Gas and Vacuum Pipeline Certification Discrepancies list dated
10/05/04 and signed by Glenn Tsuda, Medical Gas Verification Specialist,
10. Installer /MedGas Welder Documentation.
I. Scope of Verification: The medical gas system in this Level 3 Dental Facility
Verification is private practice with 3 operatories (1 future) equipped with oxygen,
nitrous oxide, compressed air and vacuum.
A Rooms /Areas include;
• Treatment Room 1
• Quiet Room
• Future Treatment Room
B. Medical Gas Systems - The following systems are included in this report:
• Oxygen
• Nitrous Oxide
• Level 3 Compressed Air
• Level 3 Vacuum
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11. Source Equipment Verification
• Oxygen Manifold
• Nitrous Oxide Manifold
+ Level 3 Compressed Air Compressor
• Level 3 Vacuum Pump
Ill. System Verification and Final Testing
A. Static Pressure rest. At normal operating pressure w/ the source gas for a
period of 24 hours with a maximum allowable pressure loss of 5 psig.
B. Pressure Relief Test. Each gas pressure relief valve shall be tested to ensure
proper operation.
C. Cross Connection. Pipelines were pressurized Individually and depressurized
to verify the absence of cross connections,
D. Pipeline Purging. All positive pressure pipelines were blown down to remove
any residual oxidation and remove any trace of nitrogen remaining from the
welding process.
E. Alarm Testing for Gas Systems. All alarms were tested for all conditions
monitored.
Other Findings and Recommendations:
The air compressor Intake Is located in the attic area above the facility, Facility
owners must be informed that storage of chemical based materials around the
compressor intake is prohibited.
•
NFPA99C - 4- 5.1.1.3 Patient Gas Supply Systems - subpara (e)
- The air intake shall be from outside the building when practical or shall be located
within a room where no chemical based material is stored or used.
This summary pre .� red by
n n Tsuda
edical Gas Verification Specialist
MedGes Certified, LLC
220 St James Ct
Longview, WA 98632
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MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
Level 3 Piped Gas Systems (Source and Distribution)
5 Q Oxygen Manifold NFPA 99, 1999 46.L [ &
Secton 4 of 6 4 -5.1.2 & 45.1.2.7 DlstrIbutioe for Patients — Level 3 (continued)
YES NO UJA
O` 0 o Flexible connectors other than all -metal construction shall not exceed 5 ft. in length and shall not penetrate wails, floors, ceilings,
or partitions, Shutoff valve or check valve shall be installed downstream of each pressure regulator. Pressure relief valve set at
0 • 50% above normal line pressure &lea be installed downstream of shutoff or check valve. Relief valves shall be brass or bronze
and designed for oxygen service.
O O System for supplying two single treatment facilities. Two cylinders of oxygen and nitrous oxide (if used). Each bank shall contain
al least an average day's supply. Switchover shag be automatic.
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Section 5 ol6 4- 5.1.28 WarNng Systems for Gases
YES NO MA
A Equipped with actuating with to alert he facility, visual and audible, at the alarm panel when the tine pressure drops 20% below
or increases 20% above normal line pressure, installed In each single treatment facility served by the supply system. Audible and
non -cancelable visual signal shall be installed to be heard and seen at a continuously attended location during the time of
operation of the facilely_
0, 0 0 Automatic changeover shall activate an uncancelable signal until the reserve supply bank has been replenished. If SU pplying two
treatment facilities both faciities shall be alarmed.
Section 6 oil 6 4-5 Level 3 Piped Systems
YES NO WA
0 0 Design and material used on the manifold are suitable for the gases and pressures involved.
0 O Cylinder connectors are gas specific.
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tat- o 0 A shutoff value or check valve is located downstream of each regulator.
,( 0 0 A relief valve located after the delivery regulators protects the final line pressure. The relief valve is sized to release if the line
u pressure exceeds 50 percent above the normal fine pressure.
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Signed Date /a t UY
dice! Gas ifrca ion Specialist
MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
W Level 3 Piped Gas Systems (Source and Distribution)
Oxygen Manifold MFPA 99, 1999 45.1_/ &
Facility Brandon Schwindt D.D.S City Tigard Slate Oregon
Section 1 of 6 4 -5.1.1 S 4- 5.1.11 Piped Gas Systems & Source Level 3
YES NO NIA
0- 0 4 Cylinders in service and in storage shall be Individually secured and located to prevent falling or being knocked over Valve
protection caps shall be secured tightly in place unless the cylinder is connected for use.
Section 2 of 6 4-5.1.1.2 Storage Requirements
F + YES ND NIA
O 0 Enclosure for supply systems shall be provided with doors or gates. It outside and/or rewrote from the single treatment facility, it
w shall be kept locked. If within the facility it shall be perm abaci to be locked. If located outside but adjacent to a building wail, shall
be located such that the distance to any window of the adjacent building is greater than 25 ft
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O O Enclosures shall not communicate with anesthetizing locations or storage locations for flammable anesthetizing agents.
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0 0 Doors shall be provided w/ louvered openings having a minimum of 72 sq. in. in total free area. If opening onto an exit access
corridor, a dedicated mechanical ventilation system or by natural venting shall be used.
et.. O 0 Protected so that cylinders or compressed gases shall not be heated to the activation point of integral safety devise. Never to
exceed 130 degrees F. Healing of room shall be by steam, hot water, or other indirect means. •
0- 0 0 Constructed of building materials with a fire resistive rating of at least 1 hour and shall not communicate directly with anesthetizing
locations_ No storage of flammable gases. Free of flammable materials_ Free from sources of heat_ Smoking shall be prohibited.
Electric installation complies NFPA 70, National Bectrical Code, for ordinary locations. Electric wail fixtures, switches, and
o o receptacles shall be installed in fixed locations not less than 5 ft above the floor. Open electrical conductors and transformers shall
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not be located in close praximit}r to enclosures.
Section 3 of 6 4.5.1.2 a 46,'1,2.7 Distribution for Patients —Level 3
YES NO NA
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Q 0 Manifold is equipped with two banks (primary and secondary) 10 handle at least 2 cylinders of oxygen and two cylinders of nitrous
u oxide (If used) if storage is remote, or two cylinders of oxygen and one cylinder of nitrous oxide (if used) if storage is not remote_
o o Manifold designed so that the cylinders can alternately supply the piping system. Each bank shall contain at least an average
N m day's supply. Capable of manual switching (automatic permitted). If the supply system is remote, switchover shall be automatic.
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MedGas Certified LL - Medical Gas Systems Verification
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N1= PA 99, 1909
Warning Systems for Gases Oxman
Facility Brandon Schwindt. D.D.S. City Tigard State Orecton
4- 6.9.28 Warning systems for gases
Yes No NIA
An automatic pressure switch, which will actuate a visual and audible alarm when the line pressure drops below or increases above
a normal line pressure, shall be connected to each main supply tine within a single treatment facility. Theautormatic pressure switch
shall be ehstalled downstream of any main supply line shutoff valve that may be required.
A warn! system shall be installed in each single facility served by the
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n9 A ty y supply system. The warning system shat be
comprised of an audible and noncancellable visual signal and shall be installed to be heard and seen eta continuously attended
w location during the time of operation of the Facility.
u► o o A warning system shall be installed to indicate whenever automatic changover occurs or is about to occur. The signal shall remain
uncancelable until the reserve supply bank has been replenished. The sensor alarm shall be independent of the sensor actuator
for line pressure monitoring
O O If system supplies multiple treatment facilities the automatic changeover alarm shall indicate in all facilities.
a 0 A signal shall be indicated separately for each medical gas piping system when the pressure in the main line Increases 20 % or
decreases 20 % from the normal operating pressure. The actuating switch for these signals shall be installed in the main line
immediately downstream (on the piping distribution side) of the main line shutoff valve or the source valve if the main line shutoff
valve is not required.
; 0 0 A pressure gauge shall be installed in the main line adjacent to the actuating switch. It shalt be appropriately labeled and be
�` readily visible from a standing position,
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ical Gas art tion Specialist
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CD MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
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Level 3 Piped Systems — Piped Gas Systems (Source and Disbibution)
Nitrous Oxide Manifold NFPA 99,1999 4.5.1.1 & 45,1.2
Facility _ Brandon Schwindt. 0.13.S City Tigard State Oreoon
Section 1 of 6 4-5.1.1 & 45.1.1.1 Piped Gas Syeta rre & Source Level 3
YES No WA
o p Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. Valve
protection caps shall be secured tightly in place unless the cylinder is connected for use.
Section 2 of 6 48.1.1.2 Storage Requirements
YES ItO WA
IY
0 o o Enclosure for supply systems shall be provided with doors or gates. if outside and/or remote from the single treatment Facility, ii
shall be kept locked. If within the facility it shall be permitted to be locked. If located outside, but adjacent to a building wall, shall
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be located such that the distance to any window of the adjacent building is greater than 25 ft.
fi CO a Enclosures shall not cornrnunicete with anesthefczing locations or storage locations for flammable anesthetizing agents.
4 O Doors shall be provided w1 louvered openings having a m lain um of 72 so. in. in total free area. If opening onto an exit access
corridor, a dedicated mechanical ventilation system or by natural venting shad be used.
U a Protected so that cylinders or compressed gases shall not be heated talkie activation point of integral safety devise. Never to
exceed 130 degrees F. Heating of room shall be by steam_ hot wafer, or other indirect means_
O 0 Constructed of building materials with a fire resistive rating of at least 1 hour and shall nil communicate directly with anesthetizing
locations. No storage of flammable gases. Free of flammable materials. Free from sources of heat. Smoking shall be prohibited
Q Electric installation complies w! NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and
receptacles shall be installed in fbred locations not less than bit above the floor. Open electrical conductors and transformers shall
not be located in close proximity to enclosures.
Section 3 of 6 4-5.1.2 & 4. 5.1.2.7 Distribution for Pallents - Level 3
x iD YES NO WA
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▪ CFI 4 g Manifold is equipped with two banks (primary and secoedary) to handle at least 2 cylinders of oxygen and two cylinders of ritrous
• m oxide (if used) if storage is remote, or two cylinders of oxygen and one cylinder of nitrous oxide (If used). if storage is not remote.
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N C2 FL o o Manifold designed so that the cylinders can alternately supply the piping system. Each bank shall contain at least an average
• o , day's supply, Capable of manual switching (automatic permitted)_ If the supply system is remote, swilchover shall be automatic.
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MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
o LI Level 3 Piped Systems — Piped Gas Systems (Source and Distribution)
5 a N itrous Oxide Manifold NFPA99,19924- 5.1.1&45.1.2
•
Section 4 of 6 4 -5.1.2 & 4- 5-12.7 Distribution for Patents — Level 3 (continued)
YES NO NM
et o p Flexible connectors other than all- rnetal construction shall not exceed 5 ft. in len and shall rot penetrate walls, floors, ceilings,
or partitions. Shutoff valve or check valve shall be installed downstream of each pressure regulator. Pressure relief valve set. at
J 50% above normal tine pressure shall be installed downstream of shutoff or check valve. Reef valves shall be brass or bronze
and designed for oxygen service_
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supplying I r
0 d ., Sys tem for pp y'►►9 two single treatrn�t facilities. Two cylinders of oxygen and nitrous oxide (if used). Each bank shall contain /" at least an average day's supply. Swltchover shall be automatic.
CJ Section 5 of 8 45.1.2.8 Warning Systems for Gases
YES NO IRA
Q Q Equipped with whaling switch to alert the facility, visual and audible; at the alarm panel when the line pressure drops 20% below
or increases 20% above normal line pressure. Installed in each single treatment facility served by the supply system. Audible and
nor- cancelable visual signal shall be installed to be heard and seen at a continuously attended location during the time of
operation of the facility.
a d Automatic changeover shall activate an uncancelable signal until the reserve supply bank has been replenished. If supplying two
treatment facilities both facilities shall be alarmed.
Section 8 of S 4-5 Level 3 Piped Systems
YES NO WA
. a o Design and material used on the manifold are suitable for the gases and pressures involved.
Q Q Cylinder connectors are gas specific.
0 O Ash utoff valve or check valve is located downstream of each regulator.
X a A relief valve located after the delivery regulators protects the final line pressure. The relief valve is s>zed to release if the line
pressure exceeds 50 percent as hen line pressure.
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M � I Gas I i M Specialist
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MedGas Certified LLC • Medical Gas Systems Verification
NFPA Kr, 1999
5
Warning Systems for Gases Nitrous Oxide
Facility Brandon Schwindt, D.D.S. City Tigard State Oregon
4- 5.1.2.a Warning system for gases
Yes No NIA
An automatic pressure switch, which will actuate a visual and audible alarm when the line pressure drops below or increases above
Q normal line pressure, shall be connected to each main supply fine within a single treatment facility. The automatic pressure switch
_r shall be installed downstream of any main supply line shutoff valve that may be required_
a
`'' A warning system shall be instated in each single treahnent facili served b the s I B stem_ The warni s stem shall be
�, (} � 9 SY 9 tY Y SAP Y Y n9 Y
comprised of an audible and norrcancellable visual signal and shall be installed to be heard std seen at a continuously attended
location during the time of operan of the facility.
a A warning system shall be instated to indicate whenever automatic ctiangover occurs or is about to occur. The signal shall remain
uncencellable until the reserve supply bank has been replenished. The sensor alarm shall be independent of the sensor actuator
for line pressure monitoring,
O O 0, If system supplies multiple treatment facilities the automatic changeover alarm shall indicate in all faclalres,
t i g 0 A signal shall be indicated separately for each medical gas piping system when the pressure in -the main line increases 20 % or
decreases 20 % from the normal ape rabng pressure_ The actuating switch for these signals shall be installed in the main bne
immediately downstream (on the piping distribution side) of the main line shutout valve or the source valve if the main line shutoff
valve is not required.
a Q A pressure gauge shall be instated in the main hne adjacent to the actuating switch. It shall be appropriately labeled and be
readily visible from a standing position.
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fcal as erti cation Specialist
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Medical Air Compressor Systems Certification NFPA99C 1999 Edition 4 -5 Level 3 Piped Systems
Fad lity Brandon Schwindt. D. D.S City Tiaard State Ormon
Section 1 of 4-5.1,1.3 Level 3 Patient Gas Supply Systems
YES NO PM
ai o 0 Air intake shall be from outside the building when practical or shall be located within a room where no chemical based material is
7°'� stored or used. Located where nacontarnination from vacuum system discharges or particulate matter is anticipated. Air intake
shall be taken from a space other than an operatory and other than the room or space in which there is an open or semi -open •
discharge from a level 3 vacuum system.
c)
Shall be permitted to be used to power air ed devices for evacuation only
o vent to the outside of the lxriidfng, r if the exhaust of the evacuation device is a dosed
I-
p Equipment shall be obtained from and be installed under the supervision of a manufacturer or supplier familiar with proper
a practices for its construction and use.
fbl O O includes appropriate disconnect switches, motor starting devices and motor overload protection devices. For single, duplex or
mule - compressor systems a means for activation /deactivation of each individual compressor shall be provided by the supplier or
contractor. When multiple compressors are used, alternation of ants, and a means to activate the additional units should the in-
service unit be incapable of maintaining adequate pressure shall be provided. Manual or automatic switchover is permitted.
d Q o Equipped with intake filter-mufflers of the dry type; receiver; shutoff valves; air dryer; in -tine final particulate filters rated at 5
microns, 9B % efficiency, with filter status indicator, and downstream pressure regulator to ensure the delivery of compressed air
with a maximum allowable -0.05 ppm liquid oil and 40% relative humidity at operating pressure and temperature.
0 a Equipped with a pressure relief valve, pressure gauge, sad receiver with drain plug or a manual drain or an automatic drain.
Receiver shall have the opacity tc ensure practical on/off operation of the compressors.
m 4 o O Moisture indicator shall be provided and located in the active air stream prior to or after the receiver but upstream of any system
pressure regulators. Shall indicate if the relative humidity of the compressed air exceeds 40% at line pressure and temperature;
O O Oil indicator sensor shall be located downstream of the receiver. Device shall be capable of measuring an oil concentration ut
0.05 ppm with an accuracy of + or - 0.03 ppm in compressed air at B0 to 100 psig.
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Med Gas Certified , LLC Medical Gas and Vacuum Pipeline System Verification
Medical Vacuum Pump System Certification NFPA99C 1999 Edition 4.5 Level 3 Piped Systems
Facility Brandon Schwindt. D.D.S City Tigard - State _ Oregon
Piped Vacuum Systems 44.2 Figures d- 2,12 (a), (b) (c} and (d)
YES NO WA
la O 0 Equipment shall be obtained from and be installed under the supervision of a manufacturer or supplier familiar with proper
practices for its construction and use. Wet vacuum piping systems shall have a liquid/air separator in the system,
O d Liquids from vacuum system shall be cslrecliy connected to the sanitary drainage system through an appropriately trapped and
vented drain.
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v, O O Exhaust shah be ]coaled remote from any door, window, air intake, or other openings In the building with particular attention given
p to separate levels of intake or discharge. Exhaust is protected against the entry of insects, vermin, debris, and precipitation. Sized
to minimize back pressure.
d O 0 Discharge of the vacuum systems utilizing common exhaust pipes shall be fitted with check valves, manual valves or arranged to
permit capping of the active pipe when removing and servicing a vacuum pump or components.
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Signed Date to 7C/6
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NFPA 99, 1999
51 0- System Verification and Final Testing
Facility Brandon Schwindt, D.D.S City Tigard Stale Oregon
44..7. System Verification and Final Testing
Yes No WA
0 0 0 Initial Pressure Test —All systems shall be activated with the intended use gas' at the normal operating pressure. The scarce
shin valve shall then be closed. The test shalt remain static for a period of 24 hours with a maximum allowable pressure loss of
J 5 prig. Leaks, if any, shall be located, repaired and retested.
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g_ 4 O Static Pressure Test — After was have been closed in, and all brazing fabrication completed, completion of the system shall be
made. Manifolds, regulators, hoses alarms, compressors, vacuum pumps and all accessories to the system shall be assembled
before the final testing. This test shall be conducted at normal operating pressure. The lest shall remain static for a period of 24
hours with a maxim urn allowable pressure loss of 5 psig. Leaks, if any, shall be located, repaired and retested.
O O Pressure Relief Test — Each gas pressure relief valve m the piping system shelf be tested to ensure the relief valves actuate at less
than 50% over pressure frortl their meximum operating pressure. The relef valve stroll close automatically when the excess
pressure has been released,
O O Cross Connection Test — Each gas system shall be individually charged and all outlets checked to confirm the absence of cross
connects.
•
O 0 Piping Purge Test —In order to remove any traces of particulate metier deposited in the pipelines as a result of construction, a
heavy, intermittent purging of the pipeline shall be done. This purging will be continued until a white clolh does not show any
particulate or discoloration.
o o Alarm Testing for Gas Systems — The automatic pressure switch connected to each main supply line within a single treatment
facility shall actuate a visual and audible alarm when the line pressure drops approximately 20% below or increases approximately
20% above normal lice pressure.
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Signature
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iledGa# eartffiet Lit Level I Medical Gas Systems Verification
NI= PA 991999
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Facility Br Brandon Dentistry City and State Tif lard, OR
Outlets and data Outlet and hitet Performance
Gas or Reoushtorinalion Pass Goss OuleLln at Static Dynamic Piping Piping Critical Gem Outlet Oriel Outlet Gas
Vac Room cv ; Canrseolion Rove Piassurn Pressure Puma Teel Purity Flow Teal r3 sac) Leakve Lady Labeling Out3at
Sandra Nursher Room Type Fail Teat Test (sue . psi *deft psi or Nig Bectrnr225sdpra Test 6 WWI 71 slpm Function Caroentrillons' '
02 1 Treatment Rni Pass _ Pass i it/a n/a n/a Pass n/a n/a n/a n/a Pass
J 02 Quiet Rom Pass Pass Wa Na ida Pass n/a n/a n/a ni€a � Pass
n 02 Future Treatment Room Pass Pass nla n /a n/a Pass n/a rife n/a n/a n/a Pass
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10/05/2004 22:48 FAX 2002/018
����� entitle* Lie I Medical Gas Sys Verification
NFPA99 1999
Discrepancies
Facility Dr Brandon Dentistry City and State Tigard, OR
Equipment Location Discrepancy
None noted.
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lAll discrepancies have been corrected In compliance with NFPA99C 1999 Edition. If not corrected and non - compliance
l is endorsed by Authority Having Jurisdiction (AHJ) a statement from AHJ must be provided to me. Once corrections
!have been made please fax this and any other documents to me, 360 -63e -4131. This is required before issuance of
'certification Package.
I N/A
: -: nature Print Name
Signed Date (U /‘,
M =:' ►: Gas Verification Specialist
ST Mt/d D Q3IdI1'JJ3a SbJQ21,A1 T£Tb9£909£ 9S:60 t,e0Z /90 /9t
10/05/2004 22:48 FAX 0 001/018
Meddas Certified, ILO Installer Certification
The Installer or a representative of the contracted installers of this medical gas
system, acknowledge that all components and procedures, in the assembly of this
Meld- installed piping system for the distribution of medical piped gases are in
compliance with NFPA99 installer requirements for materials, installation and
testing procedures.
References:
A. NFPA 99, Gas and Vacuum Systems - 1999 Edition, Sections:
45 Level 3 Piped Systems.
4-5.1 Piped Gas Systems (Source and Distribution)
4 -5.1.1 Source — Level 3
4- 4.1.1.2 Storage Requirements ( Location, Construction. Arrangement)
4- 5.1.1,3 Level 3 Patient Gas Supply Systems
4-5.1.1.4 Level 3 Gas- Powered Devices Supply Systems
4 -5.1.2 Distribution for Patients -- Level 3 (Manifold, Piping, Valving /Controls,
Outlets/Terminals, Alarms)
4- 5.12.8 Warning Systems for Gases
4- 5.1.2.9 Pressure Gauges for Gas Systems
4- 5.1,2.10 Gas Piping
4- 5,1.2.11 Gas Shutoff Valves
4- 5.1.2.12 Gas Station Outlets
4 -5.1.3 Distribution for Gas — Powered Devices — Level 3
4- 5.1.3.2 Gas Shutoff Valves
4-5.1.3.3 Service Outlets
4 Piped Vacuum Systems (Source and Distribution) — Level 3
4 -5.2.2 Distribution — Level 3
4 -5.3 Piped WAGD Systems — Level 3
4 -5.3.1 Source — Level 3
4 -5.3.2 Distribution — Level 3
4 - 5,4 Performance Criteria and Testing - Level 3 (Gas, Vacuum, WAGD)
4 -5.4.1 Piped Patient Gas Systems _ Level 3
4- 5.4.1.1 General
4- 5.4.1.2 Piping Integrity Test
4 -5.4.2 Piped Gas - Powered Devices Gas Systems — Level 3
4 -5.4.3 Piped Vacuum Systems — Level 3
4 -5.4.4 Piped WAGD Systems Level 3
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Installer Firm Name ��/ / ! e. 441 u • ,1n .. ( t › -
Authorized Representative ese
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Signature Date
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