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Airgas <br />(�f I UC�-G3C� <br />Airgas Medical Sarvicea, Inc. <br />everen wn sezoi <br />�azspa��eeo� �ax (�2s�saas2o <br />htlplMwx.ai�gas.aom <br />Dental Air and Vacuum Verification <br />Report <br />Date: 14 October 2011 <br />Job Number: 201635 <br />Contractor: Constantine Builders <br />Date(s) / Time(s) of Testing: 14 October 2011 / 1445 hrs <br />Facility: Perfec: Smiles <br />Dr K:�vitha Gowda <br />15 i0 SE Everett Mall Way, Suite C <br />Everett, WA 98208 <br />Scope of Work: Verify new dentai air and vacuum system, 2 chairs and 4 future. <br />Our firm certifies that the verifier(s) named in this report are properly trained and certified to <br />perform the activitiES required. All test and measurement equipment is properly calibrated and <br />maintained. As represc:ntatives of Airgas Medical Services, Inc. the verifier(s) named in this <br />report have conducted testing and verification of Medical Gas Piping Systems and related <br />equipment to certify the following on the above date. <br />General Findings: <br />A. Dental Air and Vacuum are in compliance with NFPA 99(2005ed): <br />Level 3 Dental <br />B. No crossed line were found in Dental Air and Vacuum in the area tested on the day of <br />testing. <br />C. Dental Air meets oxygen concentration, <br />D. Dental Air meets pressure requirements. <br />E. Dental Vacuum meets vacuum level requirements. <br />F. Dental Air and Vacuum system components in area tested are in compliance with <br />NFPA 99(2005ed): Level 3 Dental <br />G. Initial Line Pressure Test: PASS <br />City of Everett, Permit #: P1108-018 <br />GOWDA-10.14.11-201635 <br />Pg 1 of 3 <br />