Page 13 - Med Plaza and Cancer Center

MEDICAL VACUUM SYSTEM ANNUAL INSPECTION FORM

Facility Florida Hospital Orlando-Med Plaza Technician Anthony Voight
City/State Orlando, FL Date 12-12-17

System Inspected Med VAC System Floor/Bldg Med Plaza
Manufacturer Beacon Medaes/Baldor Equipment ID # VP-H-5CC-GR-0-F-0A1
Vacuum System Configuration Triplex Rotary Vane Motor HP 10 HP

Hours Pump #1 49,376 Pump #2 49,997 Pump #3 49,605

Is Medical Vacuum System located IAW NFPA 99 (Dedicated Mechanical Equipment Room, Adequately Ventilated, with Required
Yes Utilities, Minimum 1-HR Fire Rated)
Yes Is Medical Vacuum System Fed from Emergency Power (Essential Electrical System)
Yes Does the Medical Vacuum System consist of at least (2) Two Pumps
Yes Is the Medical Vacuum Intake & Discharge connected to the Piping by Flexible Connectors

Yes Is the Medical Vacuum System used for Analysis, Research or Teaching Laboratory
Does the Medical Vacuum System that is used for Analysis, Research or Teaching Laboratory functions have the appropriate
Yes Valves and Fluid Trap IAW NFPA 99
Yes Is the Medical Vacuum System is used for Waste Anesthetic Gas Disposal (WAGD) functions

Does the Medical Vacuum System that is used for Waste Anesthetic Gas Disposal (WAGD) functions meet the requirements of
Yes NFPA 99 (5.1.3.7.2.1)
Yes Is the Medical Vacuum Exhaust located IAW NFPA 99
Yes Is there an Inlet Isolation Valve & Check Valve for each Pump
Yes Is the Medical Vacuum Receiver equipped with a Manual Drain and Valved Bypass Arrangement

Yes Is the Medical Vacuum System Equipped with a Source Shut Off Valve
Yes Are the Local Alarms Required by NFPA 99 Present, Functioning and connected to the Master Alarms as required
Comments:

Corporate Office ∙ 4518 Clements Rd. Lakeland Florida 33811 Phone: 863-646-7555 ∙ Fax 863-646-2999
“Medical Gas Pipeline Equipment Service, Sales & Verifications”
www.medgaspro.org