Page 7 - Select Specialty

MEDICAL VACUUM SYSTEM ANNUAL INSPECTION FORM

Facility Select Specialty Hospital-Orlando Technician Anthony Voight
City/State Orlando, FL Date 12-12-17

System Inspected Med VAC Floor/Bldg Basement
Manufacturer Beacon/Busch Equipment ID #
Model# LVS-5D-HA120-D4 Serial # 146474-1

Vacuum System Configuration Duplex stack vertical tank Motor HP 5 HP
Hours Pump#1 5,651 Pump#2 5,656 Pump#3 -- Pump#4 --

Is Medical Vacuum System located IAW NFPA 99 (Dedicated Mechanical Equipment Room, Adequately Ventilated, with
PASS Required Utilities, Minimum 1-HR Fire Rated)
PASS Is Medical Vacuum System Fed from Emergency Power (Essential Electrical System)

PASS Does the Medical Vacuum System consist of at least (2) Two Pumps
PASS Is the Medical Vacuum Intake & Discharge connected to the Piping by Flexible Connectors
NO 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
N/A Valves and Fluid Trap IAW NFPA 99
NO 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
N/A NFPA 99 (5.1.3.7.2.1)
PASS Is the Medical Vacuum Exhaust located IAW NFPA 99
PASS Is there an Inlet Isolation Valve & Check Valve for each Pump

PASS Is the Medical Vacuum Receiver equipped with a Manual Drain and Valved Bypass Arrangement
PASS Is the Medical Vacuum System Equipped with a Source Shut Off Valve
PASS 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