Page 16 - Med Plaza and Cancer Center

MEDICAL MANIFOLD SYSTEM ANNUAL INSPECTION FORM

Facility Florida Hospital Orlando Med Plaza Technician Anthony Voight
City/State Orlando, FL Date 12-12-17
System Inspected N2O Manifold Floor/Bldg Loading dock

Manufacturer Amico Equipment ID # GM-P-5PC-01-NO-E-07
Model# M2HD-DHHH-U-N2O Serial # 20091202-P-A
Manifold Type HP Gas Type N2O
Primary Cylinders 4 Secondary Cylinders 4 Reserve Cylinders -

Is Manifold System located IAW NFPA 99 (Dedicated Enclosure, Adequately Ventilated, with Required Utilities, Minimum 1-
YES HR Fire Rated, Electrical Devices located at or above 5 ft)
YES Is Manifold System Fed from Emergency Power (Essential Electrical System)
YES Is the Manifold Enclosure free of any Flammable Materials, Liquids or Gases
YES Are all Gas Cylinders (Full, Empty, Connected or unconnected) Secured to prevent them from falling

YES Is the Manifold Enclosure Secured and properly labeled IAW NFPA 99
Does the Manifold System consist of at least (2) Two Banks of Cylinders/Containers each capable of supplying an average
YES days supply of gas IAW NFPA 99
YES Does Each Bank/Header of Cylinders/Containers have an Isolation Valve
YES Does each Cylinder/Container Connection on the Header have a Check Valve to prevent backflow

YES Does each Bank/Header of Cylinders have a Pressure Gauge to indicate Header Contents
YES Does each Bank/Header have a Primary/Bank Regulator
YES Are there Check Valves installed between Primary/Bank Regulators and Final Line Regulators

YES Are Gas Cylinders/Containers prevented from exposure to Temperatures above 130 F
YES Does the Manifold have Duplex Final Line Regulators
YES Does the Manifold have the Pressure Relief Valves Required IAW NFPA 99

YES Are the Pressure Relief Valves Vented to the Outside IAW NFPA 99
YES Does the Manifold provide an Automatic Means for the Secondary Supply to Supply the System (Switchover)
YES Is the Manifold System Equipped with a Source Shut Off Valve & Labeled Properly

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”
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