Report tAPE
;?,77,0;175',714,t'S GAS P isN
3614 NW 135" Circle
Vancouver, WA 98685 1,53957) J a1tipl:V1/4N t 0
360.601.1324
infoAimaginemg.com
Monday, October 21, 2019
Ryan Venne
Venne Plumbing
15145 SW Division
Sherwood, OR 97140
Dear Mr. Venne,
Imagine Medical Gas has conducted Medical Gas System Verification as specified by
NFPA 99. 2012 edition Category 3 at Oregon Academy of Dentistry Foundation, Tigard.
Oregon. The area covered was the office at 13333 Parkway Ste 100. Verification was
performed on September 27'& October 18", 2019. A detailed report is enclosed. These
systems are ready for their intended use with the following comments.
1. None
If you have need for any further documentation or have questions about test results,
please contact me at 360.601.1324
Sincere(
Don Mcllroy, CBET
NITC# 00037258, ASSE 6030 Verifier 04/03/2020
NI rcil 00037258, ASSE 6020 Inspector 04/03/2020
Page / of Pages
Level 3 System Verification & Final Testing
Facility Oregon Academy of Dentistry Foundation
Zone or Area ALL sty 4 c z or j
1
5.3.12.3.2 &3 Standing Pressure& Vacuum Test.Each positive-pressure &vacuum gas piping system shall be subjected to a ten-minute standing
pressure/vacuum test at operating line pressure/vacuum.
5.3.12.3.4 Cross-Connection Test. After closing of walls and completion of the requirements of 5.3.12.2, Initial Tests, it shall be determined that no cross-
connections of the piping systems exist
5.3.12.3.6 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(e.g.,oxygen and nitrous oxide)pipeline shall be done.
5.3.12.3.7 Verifier Piping Particulate Test. l'he cleanliness of the piping in each medical gas(e.g.,oxygen and nitrous oxide) system shall be verified.
5.3.12.3.8 Verifier Piping Purity Test. For each medical gas(e.g., oxygen and nitrous oxide)system,the purity of the piping system shall be verified.
5.3.12.3.12 Labeling. The presence and correctness of labeling required by this standard for all components(e.g., station outlets/inlets, shutoff valves,and alarm
panels) shall be verified.
1 ! I I
All Other Piping PurityPi Piping StandingPiping
Labeling
pp
Purge Press.Nac. Particulate <5 m Tot Hydrcrbs
Outlets Line Gas Test psi 0 psi or Test White Cloth Leak Test Test <5 ppm Hal Hydcrbs Pass/Fail Comment-Itpipe,Valves
Yes/NoPass/Fail Pass/Fail < ling + , &Alarms
Tot Hyd Hal Hyd
1. ' Oxygen c,56 Ye-5 4.5c
f r' �'4-/ - .4 1 s ' ,SS
2. Nitrous Oxide (] )/�S fc' L . ! ..1 KSS ��sS
Comments
Si nature Q
!; `l ._ Date 9/27/19 Page Z— of
Level 3 Verification
Warning Systems & Emergency Shutoff Valves
Facility Oregon Academy of Dentistry Foundation
Manufacturer Porter Model Vanguard
Gas supplied Nitrous Oxide & Oxygen Serial
Line Standard Pass/Fail Comment#
5.3.6.23.3.6 Level 3 Warning Systems. Warning systems for medical gases
(e.g., oxygen and nitrous oxide) in Level 3 facilities shall provide the alarm
functions of a Level I facility as required in 5.1.9,except as follows:
(I) Area and local alarms shall not he required.
(2) Warning systems shall be permitted to have a single alarm panel.
(3)The alarm panel shall he located in an area of continuous surveillance
while the facility is in operation.
(4) Pressure switches/sensors that monitor main line pressure shall he
mounted at the source equipment with a pressure indicator at the alarm panel.
(5)Changeover alarms to suit the arrangement of the source equipment
shall be provided.
(6)A signal shall indicate separately for each medical gas piping system
when pressure in the main line increases 20%or decreases 20% from the
normal operating pressure.
(7) Systems for gases such as compressed air or nitrogen used to power
devices,as well as Level 3 vacuum systems, shall not be required to have
warnin2 s stems.
2. 5.3.6.19 Emergency Shutoff Valves Where the supply is remote from a
single treatment facility, the main supply line shall he provided with a
shutoff valve so located in the single treatment facility as to be accessible
from use-point locations in an emergency. Such valves shall be labeled to
indicate the gas controlled and shall shut off only the gas to that single
treatment facility. A remotely activated shutoff at the supply cylinder
shall not be used for emergency shutoff. For clinical purposes, such a
remote actuator shall not fail-closed in the event of a loss of electric power. If .••
remote actuators are the type that fail-open, it shall be mandatory that
cylinder shutoff valves be closed whenever the system is not in use.
Notes:
Signature Date 1 0/1 8/1 9 Page of
_ _
Level 3 Verification
Medical Gas Enclosure
Facility Oregon Academy of Dentistry Foundation
Location of enclosure Off Hallway
Location Remote_ Location Not Remote XXX
Gases housed in this enclosure Nitrous Oxide & Oxygen
Line Standard Pass/Fail Comrnent#
5.1.3.3.2 Indoor enclosures shall be constructed of an assembly of building
materials with a fire resistance rating of at least 1 hour.
2. 5.3.6.20.10 Enclosures shall not communicate directly with anesthetizing or
storage locations for flammable anesthetizing agents. 45'
3. 5.3.6.20.8 Locations for supply systems shall not be used for storage purposes
0
other than for containers of nonflammable gases except that storage of full or
465
empty containers shall be permitted.
4. 5.3.6.20.5 Air compressors and vacuum pumps shall be located separately
from other medical gas systems or cylinder storage enclosures.
1)4 I
5. 5.3.6.20.9 Flammable gases shall not be stored with oxidizing agents. °
6. 5.3.6.20.3 Enclosures for medical gases shall serve no other purpose.
7. 5.1.3.3.1.6 Enclosures shall not be located in close proximity to open electrical
conductors,transformers, storage tanks for flammable or combustible liquids. -Pc,$)
8. '-5.3.6,20.5 Doors and Gates. Enclosures for medical gas supply systems shall
be rovided with doors or _ates and if remote must be lockable. Pe4
9. 5.3.6.20.1 Gas storage locations in facilities with Category 3 medical gas
systems with a total of all gases in cylinders or containers,except
nitrogen,connected and in storage at one time that does not exceed 85 m3
(3000 ft3) at standard temperature and pressure (STP),or 142 m3 (5000 p
ft3) (STP) if oxygen is stored in a DOT Specification 41, (cryogenic liquid)
container shall comply with 5.3.6.20.3 through 5.3.6.20.12
10. 5.1.3.1.8 Locations containing medical gases other than oxygen(Oxygen
Only**)shall have their door(s) labeled substantially as follows:
CAUTK)N**
Medical Gases**
NO Smoking or Open Flame** -74t
Room May Have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering
I I. 9.3.7 Medical Gas Storille Meet ventilation requirements 9.3.7.1 to 9.3.7.8 la55
12. 5.1.3.3.2 Heating(where required) shall be by steam, hot water,or other
indirect means. Where enclosures(interior or exterior) for medical gas supply
systems are located near sources of heat, such as furnaces, incinerators,or
g5c
boiler rooms,they shall be of construction that protects cylinders from
reaching temperatures 54°C (130°F).
Notes:
Signature Date 1 0/1 8/19 Page of
Level 3 Verification
Medical Gas Manifold Source
Facility Oregon Academy of Dentistry Foundation
Manufacturer Porter Model, Vanguard
Gas supplied Nitrous Oxide & Oxygen Serial
Line Standard Pass/Fail Comment#
1 5.3.6.21.1 Mechanical means shall be provided to ensure the connection of
cylinders containing the correct gas to the piping system. Shall comply withtQt
jJ
CGA Pamphlet V-5 & V-1
2 5.3.6.21.4-6 A shutoff valve or check valve shall be installed downstream of
each pressure regulator. (B) A pressure relief valve set at 50 percent above
normal line pressure shall be installed downstream of the shutoff valve or
check valve required in 5.3.3.4.2(A). (C) Pressure relief valves shall be of 1�t
brass, bronze,or stainless steel and designed for oxygen service.
3. 5.3.6.21.7 Flexible connectors of other than all-metal construction used to
connect outlets of pressure regulators to fixed piping shall not exceed 1520
mm (5 ft) in length and shall not penetrate walls, floors, ceilings, or
.artitions.
4. 15.3.6.21.10-14 Supply systems supplying only a single treatment facility
shall contain the following: The cylinders for each gas service shall be
manifolded so that the cylinders can alternately supply the piping system.
When the primary bank is unable to supply the system, the secondary bank
shall be capable of being switched to supply the system. Two banks of
cylinders each containing the greater of either at least an average day's
, supply or one of the following:
Not Remote
(1)Two cylinders of oxygen and one cylinder of nitrous oxide(if used)
(2) Tither manual or automatic switchover shall he permitted to be used. tots.
Remote
(1)'Two cylinders of oxygen and two cylinders of nitrous oxide (if used)
(2)Automatic switchover shall be_provided.
5. 5.1.3.3.2 Cylinders in service and in storage shall be individually secured and 0 5(
located toprevent falling or being knocked over. )) _
6. 5.3.6 20.5 Air compressors and vacuum pumps shall be located separately
from other medical gas systems or cylinder storae enclosures.
7. 5.3.6.19 Emergency Shutoff Valves Where the supply is remote from a
single treatment facility, the main supply line shall be provided with a
shutoff valve so located in the single treatment facility as to be accessible
from use-point locations in an emergency. Such valves shall be labeled to
indicate the gas controlled and shall shut off only the gas to that single
treatment facility. A remotely activated shutoff at the supply cylinder 6,5/
shall not be used for emergency shutoff. For clinical purposes, such a
remote actuator shall not fail-closed in the event of a loss of electric power. If
remote actuators are the type that fail-open, it shall be mandatory that
cylinder shutoff valves be closed whenever the system is not in use.
Notes:
Signature 1 7 Date 10/18/19 Page , c of (rQ
MEDICAL GAS SYSTEM VERIFICATION OUTLET TESTING RESULTS
Facility A �
��� 7 iDed-- Zone
I
5.3.6.23.3.10 Op
erational Pressure Test all gas outlets with a gage pressure of(50 psi),including but
not limited to oxygen,nitrous oxide,medical air,and carbon dioxide.shall deliver 50 NI/min(1.8 SCFM)
with a pressure drop of no more than(5 psi)and static pressure of(50-55 psi). 5.3.6.23.3.11 Medical
Gas Concentration Test.After purging each system with the gas of system designation. Oxygen>99%
Oxygen:Nitrous oxide>99%Nitrous oxide
Oxygen 1st Outlet 2 nd Outlet Nitrous let Outlet
Baseline Pressure Pressure Concentration Oxide Pressure Concentration
Location Pressure drop<5psi drop<_5psi >99°!o Baseline drop<_5psi z 99%Nitrous
with flaw with flow Pressure with flow Oxide
Msmt,Units psig. Pass/Fail Pass/Fail Pass/Fail psig. Pass/Fail Pass/Fail
Chair 1 50 Pass N/A Pass 50 Pass Pass
Chair 2 50 Pass IN/A Pass 50 Pass Pass
Chair 3 50 Pass i N/A Pass 50 Pass Pass
Chair 4 50 Pass N/A Pass 50 Pass Pass
Chair 5 50 Pass N/A Pass 50 Pass i Pass
Chair 6 50 Pass N/A Pass 50 Pass Pass
•
Chair 7 50 Pass N/A Pass 50 Pass Pass
Chair 8 50 Pass N/A Pass 50 Pass Pass
Chair 9 50 Pass N/A Pass 50 Pass Pass
Chair 10 50 Pass N/A Pass 50 Pass Pass
Chair 11 50 Pass N/A Pass 50 Pass Pass
Chair 12 50 Pass N/A Pass 50 Pass Pass
i
i
1_
i
fd
Dental outiet02 N20.xlsx Signature 77
Date /0/11/6.7(1.
Page G, of