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Medical Gas Services, LLC <br /> Level 3 Verification Check List <br /> Reference NFPA 99(2012ed) <br /> Job#: 1550 <br /> Facility:George Orthodontics Tested By: DP Test Date:5.30.18 <br /> Facility: ® New El Existing Type of Facility: 1� Dental ❑ Medical Cl Veterinary Cl Lab ❑ Other: <br /> Dental Equipment ❑ Not Tested <br /> Dental Air System:® New ❑ Existing ❑ NONE Dental Vacuum System:® New ❑Existing El NONE <br /> Brand:Air Techniques Brand:Air Techniques <br /> Model#:AS30 Model#:MT10 <br /> Serial#:AS300-18030070 Serial#:MJ100-18030035 <br /> Conf:❑ Simplex ® Duplex ❑Triplex ❑ Quad Conf:®Simplex ❑ Duplex ❑Triplex El Quad <br /> Compressor Type:Reciprocating Pump Type:Vane <br /> Compressor On:90 psi Compressor Off:120 psi Vac Level:6"HgV Horse Power:1.5 hp. <br /> Line Pressure: 120 psi Particulate:® Pass El Fail Drain:❑Sealed ® Open ® Floor ❑Wall <br /> Concentration:20.8% Horse Power: .75 hp. Flexible Connectors: ®Yes ❑ No <br /> Receiver:®Yes ❑ No Drain:® Manual ❑Auto Air!Water Separator: ®Yes ❑ No <br /> Intake: ❑Outside ® Inside(other) ❑ Inside(same) Piping: ❑Hard Copper ® Schedule 40 PVC <br /> Amalgam Separator <br /> ❑ New ❑ Existing ®Not Required ® None Brand: <br /> Model#: Serial#: <br /> Comments: <br /> Permit: P1708-003 City of Everett <br /> Installer: Mark Sutin <br /> Address 4727 Evergreen WAY#B <br /> GeorgeOrthodontics-5.30.18-Chklst-Level 3 Verification P <br /> / <br /> 1 <br />