Report Medical Gas Services, LLC - pLri\ ,101
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Medical Gas Services,LLC
6355 NE 151st Street
Kenmore,WA 98028
425-877-9623
Dental Gas Line Verification
Report
Date: May 23, 2018 S0.�1e
Job Number: 1440
Contractor: Cascade Plumbing
Date(s) and Time(s) of Testing: May 22, 2018 - 1300hrs
Facility: Advanced Endodontics
12115 SW 70th AVE
#201
Tigard, OR 97223
Scope of Work: New Medical Gases, Dental Air and Vacuum
Our firm certifies that the verifier(s) named in the report are properly trained and certified to
perform the activities required. All test and measurement equipment is properly calibrated and
maintained. As a representative of Medical Gas Services, LLC the verifier(s) named in this
report have conducted testing and verification of Medical Gas piping systems and related
equipment to certify the following on the above date.
I. General Findings:
A. Medical Gases are in compliance with NFPA 99(2012ed): Level 3, Dental
"NOT FOR ANESTHESIA"
B. No crossed lines were found in Medical Gases in the tested areas on the day of
testing.
C. Medical Gases meet minimum concentrations.
D. Medical Gases are at normal pressure.
E. Dental Air is at normal pressure.
F. Dental Vacuum is at normal level.
G. Medical Gas and Dental system components in area tested are in compliance with
NFPA 99 (2012ed). Level 3, Dental.
H. Purge Gas: Lot#W2477293GC01 (Alrgas)
I. City of Tigard: Permit# PLM2018-00014
J. Attachments: Worksheet
Note: Existing Equipment and Systems.
NFPA 99(2012ed) #5.3.1.4 -An existing Level 3 system that is not in strict
compliance with the provisions of this standard shall be permitted to be continued
in use as long as the authority having jurisdiction has determined that such use
does not constitute a distinct hazard to life.
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g 3
Medical Gas Services, LLC
Medical Gas Services,LLC
6355 NE 151st Street
Kenmore,WA 98028
425-877-9623
II. Medical Gases
A. Oxygen:
1. Static line pressure: 50 psig.
2. Oxygen concentration at outlet: >99.0%
3. Dynamic outlet free flow at outlet: >3.5 scfm
B. Nitrous Oxide:
1. Static line pressure: 50 psig.
2. Nitrous Oxide concentration at outlet: >99.0%
3. Dynamic outlet free flow at outlet: >3.5 scfm
Ill. Dental Air and Vacuum:
A. Dental Air:
1. Static line pressure: 120 psig.
2. Oxygen concentration at outlet: 20.8%
B. Dental Vacuum:
1. Static line vacuum: 9 "HgV.
IV. Particulate Line Test: PASS
V. Odor: PASS
VI. Outlet:
A. Outlet Style: DISS
VII. Manifold/Alarm:
A. Manifold: New
1. Brand: Porter
2. Model Number: 4222NOHF-1
3. Serial Number: 42H1-3976
B. Alarm: New
1. Brand: Porter
2. Model Number: Vanguard B
3. Serial Number: KD115951
AdvEndo-5.23.18-VR-Dental Gas Line Pg. 2 of 3
Medical Gas Services, LLC
Medical Gas Services,LLC
6355 NE 151st Street
Kenmore,WA 98028
425-877-9623
VIII. Dental Equipment:
A. Dental Air: New
1. System air components in compliance with NFPA 99(2012ed)
2. Brand: Air Techniques
3. Model Number: AS70
4. Serial Number: AS700-17110045
5. Configuration: Triplex
6. Intake: Inside another room
8. Pump: Oil-less
B. Dental Vacuum: New
1. System air components in compliance with NFPA 99(2012ed)
2. Brand: Air Techniques
3. Model Number: Mojave MMC
4. Serial Number: MJ001-17110061
5. Configuration: Duplex
6. Vented to outside. Yes
C. Amalgam Separator: New
1. Brand: Air Techniques
2. Model Number: Acadia
X. Cylinder Storage:
A. Location: Inside
B. Ventilation: Mechanical
C. Cooling Sprinkler: Yes
D. Door labeled: Yes
E. 1 Hour Rated: Yes
F. Cylinders Secured: Yes
Xl. Brazier: Sean Wolfe
A. Brazier Number: 10171010171-12
B. Plumbing Contractor: Cascade Plumbing
XII. Comments:
A. None
XIII. Recommended Corrections:
A. None
Tested By: Harry Pomeranz —ASSE 6030 Verifier
AdvEndo-5.23.18-VR-Dental Gas Line Pg. 3 of 3
Medical Gasics Services, LLC
Level 3 Verification Check:
List
Reference NFPA 99(2012ed)
Test Date:
Job5/22/18#: 1440
Facility:Advanced EndodontTested DP
Facility: ® New 9 Existing Type of Facility: ® Dental 9 Medical 9 Veterinary 9 Lab ❑ Other:
Medical Gases ❑ NONE
Oxygen Line:Z New 9 Existing Nitrous Oxide Line:® New 9 Existing ❑ NONE
Line Pressure:50 psi Concentration:>99% Line Pressure: 50 psi Concentration: <1 %
Flow Test: SCFH(>_3.5 scfm) ® Pass 9 Fail Flow Test: SCFH(>_3.5 scfm)® Pass 9 Fail
Particulate Test: ® Pass 9 Fail Particulate Test: ® Pass 0 Fail
Odor: ® Pass(None) 9 Fail, Odor:® Pass(None) 9 Fail,
Crossed Lines:® Yes 9 No Outlet Brand: NA Quick Connect Style: DISS
Location of Outlets: 12 O'Clock
Cylinder Storage 9 NONE
Tank Room:® New 9 Existing Location: Z Inside 9 Remote Door Labeled: Yes 0 No
Individually Secured: ®Yes 9 No Cooling Sprinkler: ® Yes 9 No 1 Hour Rated: ®Yes 0 No
Separate from Mechanical Equipment:Z Yes 9 No Electrical Switches/Outlets 5'above floor: ® Yes 9 No
Volume Connected or Stored: Z <3000 ft3 0 >3000 ft3 Number of Cylinders Connected:OX 2 x N2O 2
Ventilation:9 Natural ® N/A Ventilation:Z Mechanical ❑ N/A
2 Openings 1'of Floor&Ceiling:9 Yes ❑ No .1 N/A Exhaust Fan Runs Continuously: ® Yes 9 No 0 N/A
Minimum 72 in2 Free Area: 9 Yes 9 No ® N/A Draws Air from within 1'of Floor: ® Yes 9 No ❑ N/A
Vented directly to outside:9 Yes 9 No ® N/A Fan Connected to Essential Power: ® Yes ❑ No 9 N/A
Manifold ❑ NONE
Manifold:® New ❑ Existing Piping Labeled:®Yes 9 No
Brand: Porter Flex Hoses<5': ® Yes 9 No/Rigid Copper 9 Yes 9 N/A
Model#:4222NOHF-1 Check Valve DL of Regulator: ® Yes 9 No
Serial#:42H1-3976 Relief Valve 50%Above Norman Line Pres: ® Yes 9 No
Alarm/Warning System ❑ NONE
Alarm: ® New 9 Existing 9 None—Not Required Non-Cancellable Visual Alarm:® Yes 9 No
Brand: Porter Cancellable Audible Alarm: ® Yes 9 No
Model#:Vanguard B HI/LO Line Pressure Alarm: ® Yes 9 No
Serial#: KD115951 Reserve In Use Alarm/Change Over: ® Yes 9 No
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Medical Gas Services, LLC
Emergency Shutoff/Zone Valve ® NONE
Valve: ❑ New ❑ Existing ® None—Not Required Brand:
3 Part Valve: ❑ Yes ❑ No With Down Line Gauges:❑Yes ❑ No Sensor Location: ❑ UL ❑ DL
Labeled:
Dental Equipment ❑ Not Tested
Dental Air System:® New ❑ Existing ❑ NONE Dental Vacuum System:® New ❑ Existing ❑ NONE
Brand:Air Techniques Brand:Air Techniques
Model#:AS70 Model#: Mojave MMC
Serial#:AS700-17110045 Serial#: MJ001-17110061
Conf:❑ Simplex ❑ Duplex ® Triplex ❑ Quad Conf: ❑ Simplex ® Duplex ❑ Triplex ❑ Quad
Compressor Type: Reciprocating Pump Type: Liquid Ring
Compressor On:90 psi Compressor Off: 120 psi Vac Level:9"HgV Horse Power: Unknown hp.
Line Pressure: 120 psi Particulate: ® Pass❑ Fail Drain: ® Sealed ❑ Open ❑ Floor 4 Wall
Concentration:20.8% Horse Power: unknown hp. Flexible Connectors: ®Yes ❑ No
Receiver: ® Yes ❑ No Drain:® Manual ❑ Auto Air/Water Separator: ® Yes ❑ No
Moisture Indicator: ® Yes ❑ No Exhausted to Outside: ® Yes ❑ No
Dryer: ® Yes ❑ No Type: Desiccant Location of Discharge: Roof
Intake: ❑ Outside ® Inside(other) ❑ Inside(same) Piping: ❑ Hard Copper ® Schedule 40 PVC
Amalgam Separator
® New ❑ Existing ❑ Not Required ❑ None Brand:Air Techniques
Model#:Acadia Serial#: Unknown
Comments:
Permit:
Installer: Sean Wolfe
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