HomeMy WebLinkAboutB14-0240_B14-0240 Medical Gas Systems report_1414601040.pdf 'x
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AIR TESTING . & /SERVICES , INC . - •
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MEDICAL GAS SYSTEMS JOBSITE VISIT&INSTALLER AFFIDAVIT FORM PER NFPA: ,1999 0 2002
�� �� ❑2005 ❑2012
Facility: VA)z VX-4.1-Ey 4/
Address: / 8I t o, /vI tY..d U, • , 014/L1 ( i �j.�`4"
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Job Description: _ i *- ' J ..ii‘— 4 • i ,A '
Contractor: fit, / Date: 1D-2 P-f
c5 /'r .7(eCt F[_ of Medical Air Testing&Services,Inc.has tested the following equipment for proper operation per NFPA 99
f Oxygen Outlets 0 WAGD Inlets
Q Vacuum Pump System
IVacuum Inlets / Area Alarm Panels Air Compressor System
ALL, Medical Air Outlets 0 Master Alarm Panels 0 Proportioning System
0 Nitrogen Outlets Zone Valves a Dental Vacuum Pump
0 Nitrous Oxide Outlets 10 Manifolds rJ Dental Air Compressor
a Carbon Dioxide Outlets 11 Bulk
JGas Systems Other:` b,04/5—
Comments: Ar r E. i 51)F . CU'G /, -77L /'r G(Sj /ALL
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NFPA 99 requires several criteria be met on behalf of the installer prior to a 3rd party verification for any medical gas system modification,
replacement, remodel,addition,or new installation that will be placed into service for patient use. Since a representative from our company
was not present throughout the entire course of the installation,it is necessary to have the installer's authorized agent complete and sign this
affidavit. I, the undersigned, do hereby declare the he following procedures and requirements have been successfully completed by the
contractor/installer to satisfy the minimum requirements set forth by NFPA 99 for medical gas system pipeline installations(unless otherwise
noted):
• The contractor/installer used required materials and practiced compliant storage/handling techniques
• The contractor/installer maintains required brazer/installer qualification credentials
• The contractor/installer used required techniques for pipeline component preparation and installation
• The contractor/installer properly labeled all required components of the medical gas system
• The contractor/installer successfully completed the Initial Piping Blow Down using oil-free,dry nitrogen NF
• The contractor/installer successfully completed Initial Pressure Test using oil-free,dry nitrogen NF at 1.5 times the system working
pressure,but not less than 150 psi(1035 kPa)for Positive Pressure Medical Gas Piping and 60 psi for Vacuum Piping(415 kpa)
• The contractor/installer successfully completed Initial Cross-Connection Test using oil-free,dry nitrogen NF at 50 psi(345 kPa)
• The contractor/installer successfully completed Initial Piping Purge Test using oil-free,dry nitrogen NF
• The contractor/installer successfully completed 24-hr Standing Pressure Test for Positive Pressure Medical Gas Piping using oil-free,
dry nitrogen NF at 20%above normal system operating line pressure
• The contractor/installer successfully completed 24-hr Standing Vacuum Test for Vacuum Piping using oil-free, dry nitrogen NF
between 12 in.(300 mm)and full vacuum
Syst (s)were verified for compliance with NFPA 99 as a Level/Category 1 1/2 3 4 Other:
V System(s)meet the minimum NFPA Healthcare Facilities Standard to which the facility was tested.
Does not meet the minimum NFPA Healthcare Facilities Standard to which the facility was tested, unless accepted by the
Authority Having Jurisdiction(Note: NFPA 99 states that"An existing system that is not in strict compliance with the provisions of
the 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.")
Please contact us for retesting if required. The interruption of any medical gas shall be the sole responsibility of the Hospital. It is the
resp ity of the hos'ital to inform all personnel of system status.This system was Installed and verified in compliance with NFPA 99 by:
/ Installer ASSE 6010 Installer#/2-J/7-5-19 Not Available
a I i acility Authorized Representative Position/Job Title M )d1S 1-� 6N6. -4ci Not Available
iir7ll�f/'��,Wr ,,I .-
Medical Air Testing&Services,Inc. ASSE 6030 Verifier# A!,//? 3i Not Available