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9Vlecgas Certified; EEC
Medical Gas cProfessionaIs
Medical Gas Verification Report
Auzins DDS
11565 SW Durham Rd Bldg. F, Suite 100
Tigard, OR 97224
"REV 1 - Level 3 Dental Facility
5 Operatory Chairs /Rooms
with
Oxygen /Nitrous Oxide"
Date of Verification: June 13, 2013 & June 27, 2013
Date of this Report: June 13, 2013 & June 27, 2013
Medical Gas Installer — Venne Plumbing
Verification performed by:
MedGas Certified, LLC
220 Saint James Ct.
Longview, WA 98632
360 -430 -2151 888 -456 -3573 (fax)
medgascertified @hotmail.corn
MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
System Verification and Final Testing Level 3 Piped Gas Systems
Project: Auzins DDS, 11565 SW Durham Rd Bldg. F, Suite 100, Tigard, OR 97224
The Medical Gas Verification Specialist Glenn Tsuda tested the Medical Pipeline System indicated by this report in
accordance with the current state enforced 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:
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:
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.
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MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
System Verification and Final Testing Level 3 Piped Gas Systems
Project: Auzins DDS, 11565 SW Durham Rd Bldg. F, Suite 100, Tigard, OR 97224
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 all 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 Level 3 Facilities are performed up to the point of the medical gas piping valves where
Level 3 equipment connections take place. Connections of Level 3 equipment, tools, dental chairs, oxygen and nitrous
oxide flow meters, are the responsibility of the Level 3 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.
NOTE: Determination of the facilities medical gas Level (1, 2 or 3) is based on the patient's imminent danger of morbidity
or mortality in the event of an interruption of the piped medical gas and vacuum systems. Level of the facility is
determined by collaboration between the owner, engineers, local authority having jurisdiction and the medical gas
equipment provider. MedGas Certified, LLC does NOT determine Level and performs the Level of inspection determined
and contracted for by this collaboration.
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MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
System Verification and Final Testing Level 3 Piped Gas Systems
Project: Auzins DDS, 11565 SW Durham Rd Bldg. F, Suite 100, Tigard, OR 97224
5.3.12.3.1.4 Verification testing shall be conducted by a party technically competent and experience in the field of medical gas and vacuum system
verification and meeting the requirements of ASSE 6030, Professional Qualifications Standard for Medical Gas Systems Verifiers.
5.3.12.3 System Verification
N/A Pass Fail Re -test
O 6/13 5.3.12.3.2 Verifier Standing Pressure Test (oxygen and nitrous oxide)
O 6/13 0 O 5.3.12.3.4 Verifier Cross — Connection Test (oxygen and nitrous oxide)
6/13 5.3.12.3.5 Verifier Level 3 Warning System Test (oxygen and nitrous oxide)
6/13 O 5.3.12.3.6 Verifier Piping Purge Test (oxygen and nitrous oxide)
6/13 5.3.12.3.7 Verifier Piping Particulate Test (oxygen and nitrous oxide)
O 6/13 0 5.3.12.3.8 Verifier Piping Purity Test (oxygen and nitrous oxide)
N/A 0 0 O 5.3.12.3.9 Verifier Final Tie -in Test (oxygen and nitrous oxide)
5.3.12.3.10 Verifier Operational Pressure Test (oxygen and nitrous oxide) - 6/27 - The old manifold was replaced
O 6/27 0 0 and passed. - 6/13 - The initial inspection with the old pre -existing manifold failed.
O 6/13 O 5.3.12.3.11 Verifier Gas Concentration Test (oxygen and nitrous oxide)
O 6/13 5.3.12.3.12 Labeling (oxygen and nitrous oxide)
5.3.12.3.12.3 Level 3 Source Equipment for Oxygen and Nitrous Oxide
N/A Pass Fail Re -test
5.3.12.3.13 Source Equipment Verification - Oxygen/ Nitrous Oxide Manifold - 6/27 - The old manifold was
0 6/27 0 0 replaced and passed. - 6/13 - The initial inspection with the old pre - existing manifold failed.
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MedGas Certified, LLC Medical Gas and Vacuum Pipeline System Verification
System Verification and Final Testing Level 3 Piped Gas Systems
Project: Auzins DDS, 11565 SW Durham Rd Bldg. F, Suite 100, Tigard, OR 97224
This project is a pre -existing system that has modified the piping, moving a set of outlets and adding 3 rooms
with outlets.
_ GKT System has been verified to and meets the Level 3 requirements of NFPA99 2002 Edition.
System has been inspected to the requirements of NFPA99 2002 Edition and found to have met these
requirements with the following notes and exceptions. Acceptance of facility or corrections to be
required must be determined by the local authority having jurisdiction.
1. 6/27 — Manifold has been replaced and now passes code flow requirements. 6/13 - Manifold is pre - existing
but fails today's code flow requirements. Because the new piping was added and new procedure /treatment
rooms, the new system must meet today's code requirements.
2. Cylinder room door is not labeled. Note: Project in finishing stages. Signage is available and will be placed
before project completion.
CAUTION
Medical Gases
NO Smoking or Open Flames
Room May Have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering
74. krt• -
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Signature Date 6/13/13 & 6/27/13
Glenn Tsuda
Medical Gas Verification Specialist
MedGas Certified, LLC, 220 Saint James Ct., Longview, WA 98632
360 -430 -2151 fax — 888 -456 -3573 medgascertified@hotmail.com
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