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Med'Icall Gas Servilces, LLC <br /> Level 3 Verification Check List <br /> Reference NFPA 99(2005ed) <br /> Job#: 798678 <br /> Facility: Dr.Alex Kang Tested By: HP Test Date: 11/20/14 <br /> Facility: ® New ❑ Existing Type of Facility: ® Dental ❑ Medical ❑Veterinary ❑ Lab ❑ Other: <br /> Medical Gases ❑ NONE <br /> Oxygen Line: ® New ❑ Existing Nitrous Oxide Line: ® New ❑ Existing ❑ NONE <br /> Line Pressure:50 psi Concentration: >99% Line Pressure: 50 psi Concentration: >99% <br /> Flow Test: SCFH (>_3.5 scfm j® Pass ❑ Fail Flow Test: SCFH (>_3.5 scfm)® Pass ❑ Fail <br /> Particulate Test: ® Pass ❑ Fail Particulate Test: ® Pass ❑ Fail <br /> Odor: ® Pass(None) ❑ Fail, Odor: ® Pass (None) ❑ Fail, <br /> Crossed Lines: ❑Yes ® No Outlet Brand: DISS fittings Quick Connect Style: NA <br /> Location of Outlets: 12 O'Clocks <br /> Cylinder Storage ❑ NONE <br /> Tank Room: ❑ New ® Existing Location: ® Inside ❑ Remote Door Labeled: ❑Yes ® No <br /> Individually Secured: ®Yes ❑ No Cooling Sprinkler: ®Yes ❑ No 1 Hour Rated: ®Yes ❑ No <br /> Separate from Mechanical Equipment: ®Yes ❑ No Electrical Switches/Outlets 5' above floor: ®Yes ❑ No <br /> Volume Connected or Stored: ® <3000 ft' ❑ >3000 ft' Number of Cylinders Connected: OX 2 x N20 2 <br /> Ventilation: ® Natural ❑ N/A Ventilation: ❑ Mechanical ® N/A <br /> 2 Openings l'of Floor&Ceiling: ®Yes ❑ No ❑ N/A Exhaust Fan Runs Continuously: ❑Yes ❑ No ® N/A <br /> Minimum 72 int Free Area: ®Yes ❑ No ❑ N/A Draws Air from within 1'of Floor: ❑Yes ❑ No ® N/A <br /> Vented to Exit Access Corridor: ❑Yes ® No ❑ N/A Fan Connected to Essential Power: ❑Yes ❑ No ®N/A <br /> Manifold ❑ NONE <br /> Manifold: ® New ❑ Existing Piping Labeled: ®Yes ❑No <br /> Brand: Porter Flex Hoses<5': ®Yes❑ No 1 Rigid Copper❑ Yes❑ N/A <br /> Model#:4222NOHF-1 Check Valve DL of Regulator: ®Yes ❑ No <br /> Serial#:42H!2624 Relief Valve 50%Above Norman Line Pres: ®Yes ❑ No <br /> Alarm/Warning System ❑ NONE <br /> Alarm: ® New ❑ Existing ❑ None—Not Required Non-Cancellable Visual Alarm: ®Yes ❑ No <br /> Brand: Porter Cancellable Audible Alarm: ®Yes ❑ No <br /> Model#:Vanguard A HI/LO Line Pressure Alarm: ® Yes ❑ No <br /> Serial#: KD98786 Reserve In Use Alarm/Change Over: ®Yes ❑ No <br /> KANG-11.20.14-Chklst-Level 3 Verification (2005ed) <br />