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11/19/2010 17:00 FAX 4257412500 NITROI INC <br />0001 <br />Nitrox, Inc - AaadlcerGases'Medcal Oes Line Venacerions'AnalOasY Equ9Yeenl' <br />2706 160 Street SW— Lynnwood, WA 98087 (425) 741-8807 Fax (425) 741-2500 <br />Inspector of Record <br />Preliminary Report X 10 <br />Date: 19 November 2010 <br />Scope of Work: New Dental Air and Vacuum systems <br />Facility: Everett Denture Center <br />Dr. Mark Cheslik <br />-4387 Rucker Ave <br />Everett, WA 98203 <br />This report is to confirm testing has been pe-formed at the following facility. if completed <br />finial repoi i io f1;!1ow in seven to tan working days. <br />Test Date: 18 November 2010 ❑ Level 1 ❑ Level 2 ® Level 3 <br />❑ Oyygen ❑ NWrous Oxide ❑ Medical Air ❑ Medical Vacuum <br />® Dental Air ® Dental Vacuum <br />Test Complete: ® Yes ❑ No (See Notes) <br />Passed: ® Yes / ❑ No, Per NFPA 99 (2005 ed) (See Notes) <br />Ready for Patient Use: ® Yes ❑ No <br />Verifier: Eric N.)3urt, ASSE 6020 <br />per NFPA 9f1 (2005ed) <br />CRTT, CMGV #V-0024 <br />President <br />TNs documenl and any attachments are conridei dial and intended solely for the intended reopient(s) If you are not the n9med <br />recipient you should not read, distnbute, copy or niter this document or Ifs atachments. <br />EVERETTDENTURECNT-11.17.10-ior Pg 1 of 1 <br />