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Medical Gas Services, LLC <br /> Level 3 Verification Check List <br /> Reference NFPA 99(2012ed) <br /> Job#:1533 <br /> Facility:Silver Lake Orthodontics Tested By:HP Test Date:9/21/18 <br /> Facility: El New [3 Existing Type of Facility: rgi Dental El Medical [3 Veterinary 0 Lab 0 Other: <br /> Medical Gases NONE <br /> Oxygen Line:0 New E3 Existing Nitrous Oxide Line:0 New 0 Existing 0 NONE <br /> Line Pressure: psi Concentration: % Line Pressure: psi Concentration: % <br /> Flow Test SCFH(?..35 scfm)0 Pass 0 Fail Flow Test SCFH( scfrn)0 Pass []Fail <br /> Particulate Test 0 Pass 0 Fail Particulate Test Ei Pass 0 Fail <br /> Odor El Pass(tbrte) 0 Fad, Odor 0 Pass(None) Fail, <br /> Crossed Lines:0 Yes E3 No Outlet Brand: Quick Connect Style: <br /> Location of Outlets: <br /> Cylinder Storage NONE <br /> Tank Room:[3 New {3 Existing Location:ID Inside 0 Remote Door labeled:0 Yes 0 No <br /> Individually Secured:[3 Yes 0 No Cooling Sprinkler: 0 Yes ID No 1 Hour Rated:DYes 0 No <br /> Separate from Mechanical Equipment[3 Yes 0 No Electrical Switches/Outlets 5'above floor DYes 0 No <br /> Volume Connected or Stored:[] <3000 ft3 0>3000 ft3 Number of Cylinders Connected:OX x N20 <br /> Ventilation:0 Natural Li N/A Ventilation:0 Mechanical El NIA <br /> 2 Openings 1'of Floor&Ceiling:0 Yes 0 No 0 N/A Exhaust Fan Runs Continuously:0 Yes No [3 N/A <br /> Mini=72 kI Free Area:0 Yes No 0 N/A Draws Air from within 1'of Floor:0 Yes [3 No Ei WA <br /> Vented directly to outside:[3 Yes 0 No 0 WA Fan Connected to Essential Power 0 Yes 0 No N/A <br /> Manifold tr1 NONE <br /> Manifold:0 New 0 Existing Piping Labeled:ci Yes Ei No <br /> Brand: Flex Hoses<5':0 Yes 0 No!Rigid Copper 0 Yes 0 N/A <br /> Model#- Check Vahre IL of Regulator Dyes []No <br /> Serial#: Relief Valve 50%Above Nonnan Line Pres:0 Yes 0 No <br /> Alarm I Warning System F.7 NONE <br /> Alarm:0 New Existing 0 None-Not Required Non-Cancellable Visual Alarm:0 Yes 0 No <br /> Brand: Cancellable Audible Alarm: 0 Yes []No <br /> Model#: HI I LO Line Pressure Alarm: Yes No <br /> Serial#: Reserve In Use Alarm I Change Over: Ei Yes ID No <br /> 11./12 <br /> SilverLakeOrthodontics-9.21.18-ChkIst-Level 3 Verification(2012ed) <br />