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Airgas pIC� IJ- 0('jS i <br /> Airgas Medical Services NW <br /> 270F— 164t° Street SW <br /> Lynnwood, WA 98087 <br /> Inspector of Ftecord <br /> Preliminary Report <br /> � <br /> Date: February 7, 2011 i <br /> I <br /> i <br /> Scope of Work: Verification of new dentai office, existing equipment i <br /> Facility: Dr. Shahim Etemad' 'r�ocrl i�c.y � <br /> 10025 19'" SE st� 02 j <br /> Everett, Wa. 9R': t <br /> � <br /> This report is to confirm tesi �as been performed at the follnwing facility. If completed <br /> finial report to follow in sevc:.� c ten working days. <br /> Test Date: :l��j111 �.�1j11 ❑ Lc vel 1 ❑ Level 2 � Level 3 <br /> ❑ Oxygen ❑ Nitrous Oxide ❑ Medical Air ❑ Medical Vacuum <br /> � Dental Air � dental Vacuurn j <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. Burt, ASSE 6020 <br /> Notes: <br /> �� ,� <br /> � ^„� � `�7 t�� <br /> � <br /> This document and any altachments are confdenhal and intended solely for the iNended recipienl(s). li you are nol lhe named <br /> recipien;you should not read,dislribule,copy or aller Ihis daumenl or iCs auachments. <br /> 01-AG.VR, IOR PRELIM-02.11 Pg 1 of 1 <br /> �/� <br /> � <br />