Source Preventative Maintenance Report

Premier Surgical Center 10000 Lincoln Drive East, Suite 301 Marlton, NJ 08053

PERFORMED BY

Major Medical Hospital Services, Inc.

SERVICE DATE TECHNCIAN PROCESSED BY

November 24, 2020 Chris Carsia Robyn Rumbos

Scope of Work Performed Major Medical Hospital Services, Inc. has evaluated the medical source equipment system on the date indicated in this report and it meets the manufacturers and hospital guidelines in accordance NFPA, JACHO, Maintenance report. The preventive maintenance & testing has been performed in accordance with the most recent guidelines available and all recommendations may not require immediate compliance. The hospital is urged to repair or replace any items that are labeled for repair if not done at the time of service, as soon as possible. Information recorded during this preventative maintenance and included in this report represents our findings on the indicated evaluation date(s) only. Source equipment monitoring will be performed periodically by the trained professionals of MMHSI and results will be presented in an electronic report. This report will be prepared following the survey and will include a summary of the results, along with recommendations for actions needed to comply with the standards noted. Corrective Actions Changed oil and filters during PM.

Recommendations No recommendations needed at this time.

Future Considerations This will be a statement regarding the overall state of the equipement and will include any recommendations for projected needs or system replacements. No corrective actions were needed at this time.

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Medical Vacuum Maintenance Record Facility: Address: Floor: System Mfg: System S/N: Date of Service:

Premier Surgical Center 10000 Lincoln Drive East, Suite 301, Marlton, NJ 08053 3rd Floor Location: Chemetron Model: 2121753 Service Area: Tuesday, November 24, 2020 Visit Type:

Ambient Temperature Minimum Run Time Disconnect Rating Pipe Inlet Size Comments: Inspected = OK Wire Condition OK Strainers NA Auto Drains NA Safety Valves OK Grease Motors OK Set Points Cut In Cut Out

Lead 19 23

Pump Room DVR3 120T Entire Facility Preventative Maintenance

76°F N/A 20.0A

System Size System Voltage Primary Fuse

Duplex 208 FNM2

Pump Type System Amperage Secondary Fuse

1"

Pipe Outlet Size

1 1/4"

Main Inlet Size

Cleaned = CL Indicator Lights Gauges Check Valves Intake Elements Alternation PS2 N/A N/A

Not Applicable = NA OK Drive Belts OK Couplings OK Control Valves OK Drip Leg OK Bearings

PS3 N/A N/A

Pump 1 Rietschle VCE 60 (02) 2121774 39 OK 100°F 104°F

Pump Time

Minutes Seconds 0 17

Horse Power Drive Bearing Carrier Bearing Voltage A/B Voltage B/C Voltage A/C Amperage T1 Amperage T2 Amperage T3

Drive Motor 1 3 94°F 92°F 208 208 209 7.8A 7.2A 7.1A

1 1/4"

Follow-up = FN Replaced = RP NA Safety Guards OK OK Water Control Valve NA NA Water Temp. In NA OK Water Temp. Out NA OK Local Alarms Tested NA

Lag 15 21

Manufacturer Model Number Serial Number Hours Condition Drive Bearing Carrier Bearing

Lube Vane Pump 20.0A 5x20mm

Lag in Use Lag currently is not in use Pump 2 Rietschle VCE 60 (02) 2121753 1369 OK 103°F 109°F

Minutes 0

Seconds 15

Pump 3 N/A N/A N/A N/A N/A N/A N/A Minutes N/A

Drive Motor 2 3 96°F 93°F 208 208 209 8.2A 8.0A 8.0A Technician Comments Changed oil and filters during PM.

3

Seconds N/A

Drive Motor 3 N/A N/A N/A N/A N/A N/A N/A N/A N/A

Pump 4 N/A N/A N/A N/A N/A N/A N/A Minutes N/A

Seconds N/A

Drive Motor 4 N/A N/A N/A N/A N/A N/A N/A N/A N/A