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Home My WebLink AboutJ33482 Treasure Coast Hospice St. LucieFACILITY:Treasure Coast Hospice CITY & STATE St. Lucie. FL CUSTOMER:Medic Air Systems CITY & STATE Port Orange, FL PO#:106256 JOB #:J33482 DATE:5/8/2020 TECH:S. McCabe Affidavit J33482 Control #NA All In One Certification Form - V2018-5.14 Medical Technology Associates Inc. Certification Medical Technology Associates 6651 102nd Ave N, Pinellas Park, FL 33782 Tel. (727) 535-3007, Fax (727) 548-8622 Certification Affidavit #J33482 Page 1 of 4 FACILITY:CITY & STATE CUSTOMER:CITY & STATE PO#:JOB #: DATE:TECH: MEDICAL GAS PIPING OXY AIR VAC N2O N2 CO2 WAGD Other ------------------------ ------------------------ ✔--------------------- ------------------------ ------------------------ ------------------------ ------------------------ H. WASTE ANESTHESIA GAS TESTING Quantity:--- I. LABORATORY SERVICES Acetic Acid Quantity:---Ethanol Quantity:---Quantity:--- Formaldehyde Quantity:---Glutaraldehyde Quantity:---Quantity:--- Ethylene Oxide Quantity:---Other Quantity:---Quantity:--- Xylene Quantity:---Other Quantity:--- J. MONITORING OTHER LABORATORY AGENTS Quantity:--- OTHER LABORATORY AGENTS Quantity:--- K. AMBIENT AIR QUALITY CONTROL Quantity:--- L. HOOD VERIFICATION Quantity:--- M. INDOOR AIR QUALITY CONTROL Quantity:--- N. AIR EXCHANGE RATE MEASUREMENTS Quantity:--- O. CLEAN ROOM TESTING (INC USP 797)Quantity:--- Date Medical Technology Associates Inc. 6651 102nd Ave N, Pinellas Park, FL 33782 Treasure Coast Hospice Medic Air Systems Acknowledgement of Services 106256 5/8/2020 J33482 S. McCabe Tel. (727) 535-3007, Fax (727) 548-8622 Comments: Certification for Upgrading Oxygen Manifold to Liquid by Liquid by High Pressure. Certification Passed CHECK APPROPRIATE BOX(ES) O-Pathalaldehyde St. Lucie. FL Port Orange, FL Nitrous Oxide Halogenated Gases F. LEAK DETECTION G. OTHER A. TOTAL SYSTEM EVALUATION B. PATIENT OUTLET TESTING C. CONSTRUCTION CERTIFICATION D. CONTAMINANT TESTING E. PARTICULATE MATTER TESTING CHECK APPROPRIATE BOX(ES) Form 100 - V2018-5.14 5/8/2020 Medic Air StstemsSean Carrigan (Print) CompanyService Acknowledged By Signature certification_field_affidavit 2 of I, Category 3 Field Affidavit Medical Gas & Vacuum Systems Inspection / Testing Services TECH:S. McCabe Steve McCabe 5/8/2020 attest to the following: DATE: FACILITY:Treasure Coast Hospice CITY & STATE St. Lucie. FL NA 4 Control Number: J33482 Certification Affidavit # Page 6651 102nd Ave N, Pinellas Park, FL 33782 Tel. (727) 535-3007, Fax (727) 548-8622 Medical Technology Associates Inc. P P = Pass, F = Fail, NA = Not Applicable P P P NFPA 2005 Edgardo Guevara Certificate #:13-0220-09 5/8/2020 Associates as of (date) , as a current appointed representative of Medical Technology have conducted tests of the Medical Gas & Vacuum System and JOB #:J33482 CUSTOMER:Medic Air Systems CITY & STATE Port Orange, FL PO#:106256 Installer Performed Tests Per NFPA99 2015 Code 5.1.12.2 have been completed. Cross Connection Test was successfully completed. Name: Certificate # : Any equipment not listed on the attached worksheets is the responsibility of the Contractor and / or Facility. NA P All tested outlets and inlets are labeled and functioning properly for flow and pressures. All tested alarm panels were located and functioning properly. All tested valves and zone valve boxes were located properly with tags and labels. Pipeline system tested was purged of the test gas Nitrogen (NF). A standing pressure test was successfully completed. The concentration of the gas delivered at each outlet was tested and is within specified standards. The Contractor and / or Facility are responsible for the identification of all the equipment to be certified. NA P Area Inspected:Oxygen Manifold P Installers and Brazer are qualified and competent under NFPA99 2015 Code 5.1.10.11.11.1. ASME or AW S and ASSE 6010. NFPA 2012 NFPA 2015 Check appropriate box(es) ✔Other Category 4Category 1 Category 2✔ supply systems) at a later date. P NA piping system (including but not limited to inlets / outlets, alarm panels, zone valve boxes, manifolds or central Medical Technology Associates, Inc will be held harmless from any liability caused by any modification of the All tested air compressor and vacuum pumps were inspected and are installed correctly. The above certification applies to the condition of the detailed, itemized list of equipment as of the date noted. NA All tested central supply systems were found to be properly located and functioning for their intended use. If this box is "X'ed" review all notes on the MTA CODE COMPLIANCE WORK SHEET before patient use. Hold Harmless Clause: Form 104 - V2018-5.14 Signed by (Contractor):Signed by (MTA, Inc.):Signed by (Facility Authority): certification_master_alarm Medical Technology Associates Inc.Certification Affidavit # J33482 Page 3 of 4 FACILITY:Treasure Coast Hospice CITY & STATE St. Lucie. FL CUSTOMER:Medic Air Systems CITY & STATE Port Orange, FL PO#:106256 JOB #:J33482 DATE:5/8/2020 TECH:S. McCabe ✓ If Code Required Set Point Master Alarm 1 Master Alarm 2 Visual Signal Audible Signal Test Switch ✔60 P NA P P P ✔40 P NA P P P ✔100 P NA P P P ✔65 P NA P P P Comment s: Main Liquid Level Low MEDICAL AIR NITROGEN OXYGEN P = Pass; F = Fail; NA = Not Applicable NITROUS OXIDE Other Vacuum Low Pressure Lag Pump In-Use Other Other VACUUM N2O High Pressure N2O Low Pressure Secondary Bank In-Use Other High Pressure Secondary Bank In-Use Other Low Pressure Secondary Bank In-Use Other Other CO2 High Pressure CO2 Low Pressure CARBON DIOXIDE Manufacturer: NA Other Reserve Liquid Level Low Reserve Pressure Low Other Air High Pressure Air Low Pressure Lag Compressor In-Use Secondary Bank In-Use Dew Point High CO Level High O2 High Pressure O2 Low Pressure Secondary Bank In-Use Reserve Liquid in Use SIGNAL Form 106 - V2018-5.14 6651 102nd Ave N, Pinellas Park, FL 33782 Tel. (727) 535-3007, Fax (727) 548-8622 Location of Master Panel 1 Nurse Station Medical Gas Master Alarm System Manufacturer: Amico Alert Model: Model: NALocation of Master Panel 2 NA certification_manifold Page 4 of 4 —✔✔ P P NA NA P P P P P P P P P P P Affidavit # Medical Technology Associates Inc. 6651 102nd Ave N, Pinellas Park, FL 33782 Tel. (727) 535-3007, Fax (727) 548-8622 Manifold Inspection Check List Certification J33482 FACILITY:Treasure Coast Hospice CITY & STATE St. Lucie. FL PO#:J33482 S. McCabe CUSTOMER:Medic Air Systems CITY & STATE Port Orange, FL DATE:5/8/2020 TECH: 106256 JOB #: Header shut off valves for each side of the manifold. Manifold has local signals per NFPA99 2015 Code 5.1.3.5.11.6. Cylinders are chained or secured from falling. Header Bar Configuration: Two equal headers each with a sufficient number of gas cylinder connections for an average day’s supply, but not fewer than two connections per header. Check valves installed between primary regulator and final line regulator. Duplex final line pressure regulators are present. Regulators can be isolated from system by ball valves or check valves. P = Pass, F = Fail, NA = Not Applicable P P P P P P Oxygen PX-LLU22OX1H 1 1 Manifold Type: check as appropriate High Pressure Cylinders Liquid Gas Reserve (if applicable) Manifold Location:Outside Manifold Cage Gas: Model #:Serial #:Manufacturer:Powerex 20200323-B Manifolds locations are to be heated by indirect means (e.g. steam, hot water) if heat is required. W alls, floors, ceilings (all six room sides) and doors are of a minimum 1-hour fire resistance rating. Location with ventilation per NFPA99 2015 Code 9.3.6.5.2. Manifolds located separately from air and vacuum systems in an area used for no other purpose. Ventilation of Manifolds and Bottle Storage Locations are per NFPA99 2015 Code 9.3.6.5.2. All Electrical devices located at or above 1520 mm (5 ft) above finished floor to avoid physical damage. Gas containers / cylinder location temperature measures < 125° F for all gases > 20° F for N20 and CO2. Area is free of flammable liquids and gases. Enclosed with lockable entry and posted with proper signage. Line pressure relief valve installed. The relief valve discharge line is vented outside for each manifold (except medical air if less than 3000 ft). Relief line is piped with copper tubing and brazed (B819 Type) and turned down and screened outside. Source valve installed in proper location, properly labeled. Piping and exhaust lines are labeled properly. Pressure at which left to right bank changeover occurs (kpa/psig) Pressure at which right to left bank changeover occurs (kpa/psig) # 1 regulator setting 50 100 100 #2 regulator setting 50 Manifolds located outdoors are rated for outdoor use. Comments: Form 109 - V2018-5.14 Emergency oxygen inlet (EOSC) present if liquid oxygen supply is remote. High pressure oxygen cylinders have pigtails complying with NFPA99 2015 Code 5.1.3.5.4 (1). P P P