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Y <br /> � MEWAt INS/ -NX )N, INC. <br /> 1731 Howe Avenue,Suite 248 - Sacramento,CA 95825 <br /> 24 Hours (416)441.2287 <br /> HOSPITAL &,C LOCATION SS�� ��. DEVICE <br /> MANUFACTURER ' 1'�`=� �.� - MODEL SERIAL NO. <br /> pz <br /> PROBLEM: HOSPITAL CODE <br /> LOCATION CODE <br /> BEC NUMBER <br /> e <br /> ANALYSIS CODES 4260 <br /> M TIME ALLOCATION <br /> DISPOSITION <br /> LAG <br /> MALFUNCTION <br /> SOLUTION: <br /> A ELECTRICAL SAFETY TESTS AND LIMITS <br /> "V=` f © CHECK®TESTS PERFORMED <br /> t§4,'*ISUAL CHECK CSS <br /> ELECTRICAL <br /> 2❑OUTLETS)8 oz. <br /> ENVIRONMENTAL <br /> 3❑CHECK)t my <br /> ❑ ❑ ❑ <br /> GENKRAI INTRA NON <br /> PATIENT CARDIAC PATIENT <br /> GROUND <br /> 4 j<RA«c, 0-152 0-15U 0-1512 AS <br /> 5 c"Ass" 100 ua 100 ua 500 ua <br /> 6ANAG! <br /> 6❑ E`Ec'woaE 50 ua 10 ua NA <br /> l....Ga <br /> INPUT <br /> 7 ElIsoL.wnorl NA 10 ua NA <br /> 8 2 ERFORMANCE TEST ti- <br /> FOLLOW-UP ACTION REQUIRED ALL TESTS WITHIN LIMITS YES <br /> NO ❑ <br /> QTY PARTS STOCK NO: COST TOTAL SCHED.MAINT. hr. <br /> OT ❑ <br /> REPAIR ST. hr. $ <br /> TRAVEL hr. $ <br /> PARTS COST TOTAL $ <br /> MISC.CHARGES $ <br /> SERVICE^ -- — <br /> CUSTOMER L / `+ ems 4C, <br /> SIGNATURE / DATE <br />