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Report q l t fi vloor Go Cong. C e o ice( g OrofessionaLs Medical Gas Verification Report "Dr Dennis Clark 9430 SW Coral St 5. ° C) • Tigard, OR 97223" Date of Certification: October 7, 2005 Date of this Report: October 12, 2005 Certification provided by: MedGas Certified, LLC 220 St James Ct. Longview, WA 98632 360 -430 -2151 360 -636 -4131 (fax) 1111 Ul +��� ea g 121 ClJadacall 22o [;n_V___6© nls Medical Pipeline Verification Report The Medical Gas Certification Specialist Glenn Tsuda tested the Medical Pipeline System indicated by this report in accordance with the 2002 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 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 2002 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 standards, said authority may require evidence of proper installation, procedure or use. The authority having jurisdiction may also refer to the listings of labeling practices of an organization that is concerned with product evaluations and is thus in a position to determine compliance with appropriate standards for the current production of listed items. Per NFPA99C 2002 Edition: The phrase "authority having jurisdiction" or its acronym AHJ, 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 chief; 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. MedGas Certified, LLC has no power, nor does it undertake, to police or enforce compliance with the contents of this document. This report is reflective of the facilities condition and if necessary, contains recommendations to comply with the current NFPA99 "Gas and Vacuum Systems" version identified by this document and enforced in the facilities location at the time of this inspection /verification. This document, in its entirety, must be presented to the local Authority Having Jurisdiction (AHJ), who has the responsibility to approve equipment, materials, an installation or a procedure, and any issues of non - compliance. The AHJ will make any and all decisions to require corrections, modifications or repairs to the medical gas system recorded in this report. The AHJ, in ali matters, has the final decision to approve the facility opening and starting patient services. NOTE: The AHJ is normally the Fire Marshall in your area. In some instances the AHJ is the Department of Health or in the case of military facilities, the Commanding Officer. You, the General Contractor or the Plumbing Contractor are responsible for identifying and providing reports to your local AHJ. NOTE: MedGas Certified, LLC has no knowledge or limited knowledge of the facilities existing medical gas systems. Determinations of all areas affected by shut downs, nitrogen purges and for final gas concentration testing is the sole responsibility of the hospital, surgery center, facility. Notification of staff to prevent accidental patient exposure to life threatening medical gas is the sole responsibility of the hospital, surgery center, facility. NOTE: Errors in pipeline mapping can result in serious injury or death due to inhalation of high levels of nitrogen or gas mixtures not suitable for human consumption. • NOTE: Pipeline verifications in Dental Facilities are performed up to the point of the medical gas piping valves where dental equipment connections take place. Connections of Dental Equipment, tools, dental chairs, oxygen and nitrous oxide flow meters, are the responsibility of the Dental Equipment Supplier. MedGas Certified, LLC has no part in the connection and verification that this equipment distributes the correct gases to the patients. Errors in gas supply can result in serious injury or death due to inhalation of high levels of gas mixtures not capable of supporting life. I MOW) tc l fj � ( 2 � (c Z ry ii (( a 3L GJJW' L'JJUVU) 141Q1dD Ptl eg�17m7o11ll©00gs Medical Gas Verification Report Summary This medical gas verification is being performed after the remodel work was completed as a requirement of the Tigard, Oregon building inspection department. Medical gas verification for a project like this would normally be done prior to the tie - in to the system. This remodel changed the office floor plan and required moving one oxygen, one nitrous oxide and two vacuum inlets. Note: This report is incomplete unless /until accompanied by the following documents: 1. Medical Gas and Vacuum Pipeline System Verification "System Verification and Final Testing" Checklist dated 10/7/05 and signed by Glenn Tsuda, Medical Gas Verification Specialist. 2. Medical Gas and Vacuum Pipeline System Verification "Pipeline Purge & Purity Test" Checklist dated 10/12/05 and signed by Glenn Tsuda, Medical Gas Verification Specialist. 3. Brazer Qualifications. Findings and Recommendations: • This Level 3 facility remodel consisting of one oxygen outlet, one nitrous oxide outlet and two vacuum inlets, meets the "System Verification and Final Testing" requirements of NFP 99 2002 Edition. I. Scope of Verification: The medical gas system in this Level 3 Facility Verification includes: A. Medical Gas Systems The following systems are included in this report: ® Oxygen O Nitrous Oxide • Dental Vacuum I. System Verification and Final Testing. A. Verifier Cross - Connection Test. After closing of walls and completion of the Initial Tests, it shall be determined that no cross - connections of the piping systems exist. B. Verifier Piping Purge Test. In order to remove any traces of particulate matter deposited in the pipelines as a result of construction, a heavy, intermittent purging of each medical gas pipeline shall be done. C. Verifier Piping Particulate Test. The cleanliness of the piping in each medical gas system shall be verified. This test shall be performed by filtering 1000 L of gas through a filter which shall not accrue no more than 1 mg of matter. • D. Verifier Piping Purity Test. For each medical gas system, the purity of the piping system shall be verified. Testing will be for Total Hydrocarbons, 1 ppm, and Halogenated Hydrocarbons, 2 ppm. E. Dew Point Test. A test for dew point shall be conducted at the outlet most remote from the source and the dew point shall not exceed -12 °C (10 °F) @ 50 psi. F. Verifier Final Tie -in Test. Each joint in the final connection between the new work and the existing system shall be leak- tested with the gas of system designation or vacuum at the normal operating pressure by means of soapy water or other means effective for use with oxygen.. G. Verifier Operational Pressure Test. Operational pressure tests shall be performed at each station outlet in the medical gas piping systems. Medical gas outlets (oxygen and nitrous oxide) shall deliver 100 I /min with a pressure drop of no more than 5 psi. H. Verifier Gas Concentration Test. After purging each piping system with the gas of system designation, each gas outlet shall be analyzed for concentration of gas, by volume. 1. Labeling. The presence and correctness of labeling required by this standard for all components shall be verified. • III. System design and installation verification A. Level 3 piped gas and vacuum systems. Remodel installation and design. D. Gas Piping. Field installed piping for the distribution of nonflammable medical piped gases. C. Piped Vacuum Systems. Remodel distribution. This summary prepared by 6/ Glenn Tsuda Medical Gas Verification Specialist MedGas Certified, LLC 220 St James Ct Longview, WA 98632 MedGas Certified, L C Medical Gas and Vacuum Pipeline System Verification System Verification and Final] Testing NFPA99 2002 Edition Level 3 Piped Gas Systems Project: 5.3.12.3 System Verification Yes No N/A -01 0 0 All tests have been performed by installer per 5.3.12.2 Initial Tests (performed with Nitrogen NF, Initial Blow Down, Initial Pressure Test for Positive - Pressure Gas Systems and Copper Level 3 Vacuum Piping, Initial Leak Tests — PVC Level 3 Vacuum Piping, Initial Cross - connection Test, Initial Piping Purge Test, Initial Standing Pressure Test for Positive - Pressure Gas Piping and Initial Standing Vacuum Test for Vacuum Systems. 0 0 (6, Installation of any manufactured assemblies supplied through flexible hoses or tubing has been completed. 0 0 Where manufactured assemblies include multiple possible connection points for terminals, each possible position shall be tested independently. Verifier Standing Pressure Test. Each positive pressure piping shall 0 0 ,d g P P e gas p p g system s a be subjected to a ten-minute standing pressure test am at operating line pressure. 0 0 ,,Q. Verifier Standing Vacuum Test. Each Level 3 vacuum piping system shall be subjected to a ten - minute standing vacuum test at operating line vacuum. %0 0 0 Verifier Cross - Connection Test. After closing of walls and completion of the Installers Initial Tests, it shall be determined that no cross connections of the piping systems exist. 5.3.12.3.5 Verifier Level 3 Warning System Tests 0 0 fns All warning systems shall be tested to ensure that all components function correctly prior to placing system into service. 0 0 , =nom Warning systems that are part of an addition to an existing piping system shall be tested prior to connection of the new piping to the existing system. 0 0 Performed after cross connection testing but before the piping purge test. Can be performed with oil free dry Nitrogen NF, gas of system designation or the operating vacuum source. 0 0 0°-. Area and local alarms shall not be required. Warning system shall be permitted to have a single alarm panel. Located in an area of continuous surveillance while the facility is in operation. 0 0 ©\ Pressure switches /sensors that monitor main line pressure shall be mounted at the source equipment with a pressure indicator at the alarm panel. 0 0 '3'0, Changeover alarms to suit the arrangement of the source equipment shall be provided. fedGas Ceutofied, LLC Medical Gas and Vacuum Pipeline System Verification System Verification and Final Testing NFPA99 2002 Edition Level 3 Piped Gas Systems 5.3.12.3.5 Verifier Level 3 Warning System Tests Yes No N/A 0 () >0,_ Audible and non - cancelable visual signals in each single treatment facility shall indicate if the pressure in the main line increases or decreases 20% from the normal operating pressure. Q 0 5 ®` Audible and non - cancelable visual signals indicate whenever automatic changeover occurs or is about to occur. • p O off. If other alarm features added that are not mandatory under 5.3.9 shall be functionally tested in accordance with their intended purpose and equipment manufacturer's recommendations. 5.3.12.3.6 Verifier Piping Purge Test ✓�` 0 In order to remove any traces of particulate matter deposited in the pipelines as a result of construction, a heavy, intermittent purging of each medical gas (e.g., oxygen and nitrous oxide) pipeline shall be done. `0— O Q Using an appropriate adapter a high purge rate (8scfm) will be established. It shall be rapidly interrupted several times until the purge produces no discoloration in a white cloth loosely held over the adapter during the purge. 5.3.12.3.7 Verifier Piping Particulate Test A ® U 0 The cleanliness of the piping in each medical gas, oxygen and nitrous oxide, shall be verified. Test gas shall be oil -free, dry Nitrogen NF or the system gas. 1000 L of gas shall be filtered through a clean, white 0.45 micron filter at a minimum flow rate of 100 NI /minute (3.5 scfm). 'N O Each zone shall be tested at the outlet most remote form the source. 0-- O Q Filter shall accrue no more than 1 mg of matter from any outlet tested. 5.3.12.3.8 Verifier Piping Purity Test -.6 O ® For each medical gas, oxygen and nitrous oxide, system, the purity of the piping system shall be verified. Test gas shall be oil -free, dry Nitrogen NF or the system gas. The test shall be for total hydrocarbons (as methane) and halogenated hydrocarbons and compared with the source gas. ®_ O O This test shall be performed at the outlet most remote form the source. The difference between the two tests shall in no case exceed, Total Hydrocarbons — 1 ppm and Halogenated Hydrocarbons — 2 ppm. 20 O ® A test for dew point shall be conducted at the outlet most remote from the source and dew point shall not exceed 12 degrees C (10 degrees F) @ 50 psig. iYedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification System Verification and Final Testing NFPA99 2002 Edition Level 3 Piped Gas Systems 5.3.12.3.9 Verifier Final Tie -in Test Yes No N/A r� 0 0 Each joint in the final connection between the new work and the existing system shall be leak- tested with the gas of system designation or vacuum at the normal operating pressure by means of soapy water or other means effective for use with oxygen. For positive - pressure gases immediately after the final connection is made and leak- tested the specific altered zone and components in the immediate zone or area that is downstream form the point or area of intrusion shall be purged per Verifier Piping Purge Test. (O 0 0 Before new piping system is used for patient care the following tests shall be performed for all medical gas, oxygen and nitrous oxide v systems. Operational pressure —Gas Concentration 5.3.12.3.10 Verifier Operational Pressure Test ® 0 0 Operational pressure tests shall be performed at each station outlet in the medical gas piping systems, oxygen and nitrous oxide where the user makes connections and disconnections. Performed with either oil -free, dry Nitrogen NF or gas of system designation. 0 0 Medical gas outlets, oxygen and nitrous oxide, shall deliver 100 NL /min with a pressure drop of no more than 5 psi and static pressure of 50 – 55 psi. 5.3.12.3.11 Verifier Gas Concentration Test After purging each piping system with the gas of system designation. each medical gas outlet, oxygen and nitrous oxide, shall be 0 for concentration of gas by volume. ✓6 0 0 Allowable concentrations shall be: Oxygen > 99 % oxygen and Nitrous Oxide > 99 % nitrous oxide 5.3.12.3.12 Labeling .0 0 0 The presence and correctness of labeling required by this standard for all components station outlets /inlets, shutoff valves, and alarm panels, shall be verified. 5.3.12.3.13 Source Equipment Verification 0 s i Source equipment verification shall be performed following the installation of the interconnecting pipelines, accessories and source equipment. 0 0 j© The functioning for the Level 3 vacuum source system shall be tested and verified before it is put into service. / Signature ' � i _ I Date /C: / er Medical Gas Verification Specialist Cv, °2 52 V nl, ilif Level 3 Medical Gas Systems Verification Pipeline Purge & Purity Test NFPA99 2002 Medical Gas Purity Test Facility: Dr Clark DDS Laboratory Piping Purity Data, Total and Halogenated Hydrocarbons, is transcribed from Laboratory Reports included in the certification package. Oxygen & Nitrous Oxide Source Bottles Laboratory Piping Purity Data Dew Point Gas Pressure Visible Visual Particulates Total Hydrocarbons Halogenated 5'c © 50 psig Type psig Moisture Odor Oil Particulates 1.0 mg @ 35 cult as Methane < 1 ppm Hydrocarbons < 2 ppm 41 °F @ 50 psig N2 50 _ n/a n/a n/a n/a n/a < 1 ppm < 1 ppm n/a Oxygen Pipeline - PASS Laboratory Piping Purity Data Dew Point Gas Visible Visual Particulates Total Hydrocarbons Halogenated 5 °c @ 50 psig Type Pressure Moisture Odor Oil Particulates 1.0 mg @ 35 cult as Methane < 1 ppm Hydrocarbons <'2 ppm 41 °F @ 50 psig 02 50 Pass _ Pass Pass Pass _ < 1 mg < 1 ppm < 1 ppm - 20 °F @ 50 psig Nitrous Oxide Pipeline - PASS Laboratory Piping Purity Data Dew Point Gas Visible Visual Particulates Total Hydrocarbons Halogenated 5 °c @ 50 psig Type Pressure Moisture Odor Oil Particulates 1.0 mg @ 35 cult as Methane < 1 ppm Hydrocarbons < 2 ppm 41°F @ 50 psig N20 50 Pass Pass Pass Pass < 1 mg < 1 ppm < 1 ppm - 20 °F @ 50 psig Laboratory Piping Purity Data Dew Point Gas Visible Visual Particulates Total Hydrocarbons Halogenated 5 °c @ 50 psig Type Pressure Moisture Odor Oil Particulates 1.0 mg @ 35 cult as Methane < 1 ppm Hydrocarbons < 2 ppm 41`F @ 50 psig _ Laboratory Piping Purity Data • Dew Point Gas Visible Visual Particulates Total Hydrocarbons Halogenated 5 °c @ 50 psig Type Pressure Moisture Odor Oil Particulates 1.0 mg @ 35 cuft as Methane < 1 ppm Hydrocarbons < 2 ppm .41°F @ 50 psig #1 Compressor - Medical Air Purity Test Dew Point Oxygen Concentration Carbon Monoxide Carbon Dioxide Gaseous Hydrocarbons Halogenated 5 °c @ 50 psig 19.5 to 23.5 % oxygen 10 ppm 500.ppm 25 ppm as methane Hydrocarbons < 2 ppm 41 °F @ 50 psig #2 Compressor - Medical Air Purity Test - N/A Dew Point Oxygen Concentration Carbon Monoxide Carbon Dioxide Gaseous Hydrocarbons Halogenated 5 °c @ 50 psig 19.5 to 23.5 % oxygen --10 ppin - 500 ppm 25 ppm as methane Hydrocarbons < 2 ppm 41 °F @ 50 psig . ------ ---- -1 \ 1 / 1 Signed At ' ,/ Date /7 = Medical Gas Verifrcatio i Specialist TRI Air Testing, Inc. Laboratory Report A Texas Research International Company 9063 Bee Caves Road Compressed Air/Gas Quality Testing Austin, Texas 78733 -6201 (512) 263 2101 (800)880 - 8378 FAX: (512) 263 - 2558 http: / /www.airtesting.com MEDGAS CERTIFIED, LLC CLARK DDS ATTN: GLENN TSUDA 220 ST. JAMES CT LONGVIEW, WA 98632 ANALYSIIS RESULTS Report Number: 38014 - 0 Report Date: 10 /12/05 Customer No: 1)000233 - 1 Air /Gas Source: 02 Order Number: 21247 Air /Gas Sampled From: 02 SOURCE Sample Date: 10/07/05 Compared to Air /Gas Specification: NFPA99 SAMPLE ANALYSIS REPORT (see below) (1.0) Date Received: 10/1 1/05 Date Analyzed: 10/11/05 These test results may be used to determine it this sample meets the applicable NFPA99 specification. ANALYTE SOURCE REPORTING AIR/GAS LIMITS Total Gaseous Hydrocarbons - Methane (ppmv) < 1 1 Halogenated Hydrocarbons (ppmv) < 1 N/A = Not Applicable This report shows test results only. No comparisons to any specifications have been made. Analyzed By: VICKY EVANS Using: 70SOP•36 REV3& 70SOP - REV4 GC:70.09 BALANCE • 70 -03 Sample Media: S B: KA417 A B: Filter: HH: 417 Results relate only to items tested. This test report shall not be reproduced except in full, without written approval of TRI Air Testing, Inc American Industrial Hygiene Association Accredited Laboratory Since 1980 �� / j/v Page: 1 of 1 End Report Ed Go a, 'h.1)., CH, Laboratory Director TRI Air Testing, Inc. Laboratory Report A Texas Research International Company 9063 Bee Caves Road Compressed Air /Gas Quality `Nesting Austin, Texas 78733 -6201 (512) 263-2101 (800)880 -8378 FAX: (512) 263 -2558 http: / /www.airtesting.com MEDGAS CERTIFIED, LLC DR. DENNIS CLARK DDS ATTN: GLENN TSUDA 220 ST. JAMES CT LONGVIEW, WA 98632 ANALYSIS ' ESULTS Report Number: 38013 - 0 Report Date: 10/12/05 Customer No: D000233 - 1 Air /Gas Source: 02 . - Order Number: 21247 Air /Gas Sampled From: 02 PIPELINE Sample Date: 10/07/05 Compared to Air /Gas Specification: NFPA99 SAMPLE ANALYSIS REPORT (see below) (1.0) Date Received: 10/11/05 Date Analyzed: 10/11/05 These test results may be used to determine it this sample meets the applicable NFPA99 specification. ANALYTE SOURCE REPORTING AIR /GAS LIMITS Total Gaseous Hydrocarbons- Methane (ppmv) < 1 1 Halogenated Hydrocarbons (ppmv) < 1 • N/A = Not Applicable This report shows lest results only. No comparisons to any specifications have been made. Analyzed By: VICKY EVANS Using: 70SOP -36 REV3 & 70SOP -41 REV4 GC: 70 -09 BALANCE :70-03 Sample Media: S B: KA177 A B: Filter: HH: 177 Results relate only to kerns tested. This test report shall not be reproduced except in full, without written approval of TRI Air Testing, Inc American Industrial Hygiene Association �o% Accredited Laboratory Since 1980 ' W O ' Page: 1 of 1 End Report Ed Go a, - h.D., CIH, Laboratory Director • • ;fi T: • TRI Air Testing Inc. Laboratory Report A Texas Research i nternational Company 9063 Bee Caves Road Compressed AwIGas Quality Testing Austin, Texas 78733 -6201 (512) 263- 2101 (800)880 -8378 FAX: (512) 263 -2558 http: / /www.airtesting.com MEDGAS CERTIFIED, LLC CLARK DDS ATTN: GLENN TSUDA 220 ST. JAMES CT LONGVIEW, WA 98632 • AI !ALYSDS RESULTS Report Number: 38006 - 0 Report Date: 10/12/05 Customer No: D000233 - I Air /Gas Source: N20 Order Number: 21247 Air /Gas Sampled From: N20 SOURCE Sample Date: 10/07/05 Compared to Air /Gas Specification: NFPA99 SAMPLE ANALYSIS REPORT (see below) (1.0) Date Received: 10/11/05 Date Analyzed: 10/11/05 These test results maybe used to determine if this sample meets the applicable NFPA99 specification. ANALYTE SOURCE REPORTING AIR/GAS LIMITS Total Gaseous Hydrocarbons - Methane (ppmv) < 1 1 Halogenated Hydrocarbons (ppmv) < 1 1 NIA = Not Applicable This report shows lest results only. No comparisons to any specifications have been made. Analyzed By: VICKY EVANS Using: 70S0P -36 REVS & 7OSOP -41 REV4 GC: 70 -09 BALANCE :70 -03 Sample Media: S B: KA411 A B: Filter: HH: 411 • Results relate only to items tested. This test report shall not be reproduced except in full, without written approval of TRI Air Testing, Inc American Industrial Hygiene Association A% Accredited Laboratory Since 1980 " j / Page: 1 of 1 End Report Ed Go a , 'h -D., CIH, Laboratory Director • TRI Air Testing, Inc. Laboratory Report A Texas Research International Company 9063 Bee Caves Road Compressed tr /Gas Quae'ty Testing Austin, Texas 78733 -6201 (512) 263 - 2101 (800)880 - 8378 FAX: (512) 263 - 2558 http: / /www.airtesting.com MEDGAS CERTIFIED, L.L.0 CLARK DDS ATTN: GLENN TSUDA 2 20 ST. JAMES CI LONGVIEW, WA 98632 ANALYSIS 'ESULTS !Report Number: 38005 - 0 Report Date: 10/12/05 Customer No: D000233 - I Air /Gas Source: N Order Number: 21247 Air /Gas Sampled From: N20 PIPELINE Sample Date: 10/07/05 Com pared to Air /Gas Specification: NFPA99 SAMPLE ANALYSIS REPORT (see below) (1.0) Date Received: 10/1 1 /05 Date Analyzed: 10/1 1/05 • These test results may be used to determine it this sample meets the applicable NFPA99 specilication, ANALYTE SOURCE REPORTING AIR /GAS LIMITS Total Gaseous Hydrocarbons - Methane (ppmv) < 1 1 Halogenated Hydrocarbons (ppmv) < 1 1 • NIA = Not Applicable This report shows test results only. No comparisons to any specifications have been made. Analyzed By: VICKY EVANS Using: 7090P -36 r1EV3 & 70SOP -41 REV4 GC: 70 -09 BALANCE :70 -03 Sample Media: S B: KA218 A B: Filter: HH: 218 Results relate only to items tested. This test report shall not be reproduced except in full, without written approval of TRI Air Testing, Inc American Industrial Hygiene Association 10% Accredited Laboratory Since 1980 WAT / Page: 1 of 1 End Report Ed Go'a, "h.D., CIH, Laboratory Director N CD .` I r /i•-. • W ,� / ,-�. _ -s-77 J - %. _ - _ -4.4,,77,-,44:- -, "._-_ _ _ :mac j , - -:. _ �r _ y t / <a '� • ! c' .- . r • l ' , 1 • ._ � 1 , , 1 � 1 ``~ . "' • il ,j i , � 1 ` _ :, i ' , f � i,` h ' . - ; .J ' ` � : - -: j j � , � �, �, ./ ,t I:1\ �. : { j � •� � : . l i �. • / -= ' ?f This is to certify that 1,475.t.-- ,4 LI 7 5 .t. - : _ " _: � ::. ; D avid Haywood `; = ,.:::"„,____:: cr,. ;,:::k.i......::,-.;:;..i.... .7_, i:- ::_...:.,:!:,., • : co .-E- �: � - . �; � ,., h as completed a 32 hour course and all requirements of ���� r :. j ' ,_ .� � ..' AS SE 6010 and NFPA 99 ,� ,., : o : 'I` ,. for certification as a ;; __ H o 3 r � � - . ::: .1; ` 6 /V1edical Gas I nstaller" � �•, �s „4. 1 -. :. " : conducted by {' ;: tt ^`. is I"i. s .) >r-- j ! . t ,..k.": •.,1' : AM/ Johnson & Associates ' - ' - March 25 -28 2002 Chen�eketa Community College /: .,�, { ,r ry Course Instructor IA' ;i . .' 1 / 47 , I ' IA-----, o \s ,t,. ..• ..: ):: •_ , . � ., ` �,::.4':. x y:', :'`'! cn m� ,. � -., :.. .. .. .:....- : -... -...._.. -:. '•' - - - _ - - - - - - - - - - - - - - - - - 3',l�:L_. , } DTI ' o - `1. 1.0 j! _ i t• t I •' -t n !r. .i i•t. .t o '' j' -. . 1 . -. .• !r - • '' j ' N ..' . r I \ ,.•. \• ,`�..� -\ i��`�\ ! 1 i'. ` ', �� f i " \ ... j . y .•� ` �,..�. �• • { / J1V „.- . 0 09/27/2005 09:01 5036679891 WOLCOTT PLUMBING PAGE 02/ RECORD OF BILXZER QUALIFICATION TESTS NFPA 99.93/96/99 and ASM1ME Section ix Brazer Name: David Haywood SS Number: 563 -25 -9329 I.D. Number: 692 OR Using Brazing Procedure Specification Number: 0750 Revision: Cr T VARIABLE RECORD OF ACTUAL VALUES QUALIFICATION USED IN QUALIFICATION RANGE Material Spec. (QB -402) Type 3/4" dia. ASTM B88 Type L Tube Type K, L, M & ACR *Thickness 0.045" nominal 0.023" through 0.090" *P- Number . 107 All Copper Alloys of P -I07 Filler Metal (QB -403) Specification No. AWS A 5.8 AWS A5.8 "Class BCuP -5 All BCuP Series *F- Number 103 All F -103 fillers *Product Form Rod Rod. no preplaced inserts "Internal Purge Gas Nitrogen @ 15 CFH Nitrogen Internal Purge Flow Positions (QB -307) * Position of Test Coupons Vertical (up & downhill) & Horizontal All Flow Positions Method of Applying Filler Metal Face Feed Face Feed Joint Types (QB -408) *Type of Joint Socket All Sockets & Laps "Joint Clearance 0.003" nominal 0.002" through 0.006" "Length Overlap 0.750" Full socket depth Technique. (Q13-410) Method Manual Manual "Cleaning Emory sand & clean cloth wipe, Same water wipe & SS wire brush when cooled ° These arc Essential Variables per ASME Sec IX ^These are Essential Variables per NFPA 99 93/96/99 FULL SECTION TENSILE TEST RESULTS * *QW-153.1d allows 5% reduction in tensile if failure is in the base metal (28 500). Specification Thickness O.D. Area Ultimate Total Ultimate Unit Type of Failure Identification Inches Inches Inches Load - lbs Stress - lbs and Location Horizontal 0.040 0.874 0.1049 3700 35,272 Ductile - tube Vertical 0.040 0.874 0.1049 3375 32,173 Ductile - tube Visual Inspection of Inside of Test Coupons: Satisfactory, no flaking or oxickition Brazing Date: 3/28/2002 Brazing Performance Tests Conducted By: AW Johnson & Associates We certify that the statements in this record are true and correct, and We accept the BPQR information stated herein and that the test brazes were prepared, brazed, and tested In accordance the responsibility of such. with the requirements of NFPA 99 -93%99 and ASME Section IX. AW Johnson &. Associates Wolcott Plumbing Inc. Gresham, OR Fall brook, CA /a n tati SGf cc 5//v/0 Alan Johnson, Date Repr =live Date