Page 11 - Womens Pavilion

MEDICAL VACUUM SYSTEM ANNUAL INSPECTION FORM

Facility Florida Hospital Orlando-Women’s Technician Anthony Voight
City/State Orlando, FL Date 12-11-17

System Inspected Med VAC #7 Floor/Bldg Ground Floor Women’s
Manufacturer Beacon Equipment ID # No FL Hosp. #
Model# 4107108709 Serial # HOP300755

Vacuum System Configuration Triplex Claw Motor HP 15 HP
Hours Pump#1 5,185 Pump#2 5,193 Pump#3 1,103 Pump#4 -

Is Medical Vacuum System located IAW NFPA 99 (Dedicated Mechanical Equipment Room, Adequately Ventilated, with
YES Required 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
n/a 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
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”
©Daniel Voight 2009