Date
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OXYGEN BULK SUPPLY SYSTEM
Medical Gas and Vacuum Systems Inspection/Testing
SCHEMATIC PER NFPA 99, 2002
HOSPITAL'S GAS SUPPLY SOURCE
Source
Valve
Main
Valve
Gauge
V
Primary Contents
Indicator/Switch
Demand Check
EOSC
(Check or
Ball valve)
Primary
Container
Ball Valve
Vent Piped Outside
Line Pressure
Regulators
Pressure Switch
Pressure Regulator
Check Valve (Flow in direction of point)
High-Pressure Valve
Relief Valve
Reserve in Use
Alarm Switch
Reserve Low
Switch
Reserve Contents
Indicator/Switch
Vaporizer
Either
Reserve
Container
psi
Reserve
Header
Reserve Pressure
Low Switch
Economizer
SYSTEM INFORMATION
Location
Facility area(s) served
Bulk Supplier/Equipment Owner
National Board Number (Primary)
National Board Number (Reserve)
Primary Tank Liquid Level
Primary Tank Pressure
Intermediate Regulator Pressure
Reserve Tank Liquid Level
Reserve Tank Pressure
Reserve Regulator Pressure
Final Line Pressure (1)
Final Line Pressure (2)
Source Valve Pressure
Main Valve Pressure
INSPECTION CHECK LIST
PASS
Receiving Dock
Tank(s) and/or Cylinders adequately secured
Pass
Womens' Center Piped with copper, brass, or stainless
Pass
National Crygenics Adequate Pressure Reliefs
Pass
Lockable Entry
Pass
324234
"Oxygen, No Smoking, No Open Flames" Labels
Pass
13213
152
"H2O Cylinder Checks Installed
Pass
135
psi
Adequate Emergency Oxygen Fill Connect (EOSC)
Pass
121
psi
EOSC enclosure secured & labeled
89
"H2O Source valve, main valve, check, line pressure switch, gauge, labelingPass
122
psi
Adequate Master Alarm Switches
Pass
65
psi
Adequate concrete fill pad (3' in diameter)
Pass
54
psi
Not exposed to failure of electrical power lines
Pass
0
psi
Free of Flammable liquids & gases
Pass
50' from wood framed building, 10' from building openings, 1' from all
Pass
78
psi
structures, 25 or 50' from flammable liquid storage (</=1000 or >1000 ft3),
54
psi
FAIL
Fail
25 or 50' from slow or rapid burning solids, 50' from public assembly, & 10'
from public sidewalks or parked vehicles
Copyright Evergreen Medical Services, Inc. ; 2002
Hospital
City, State