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AL <br /> MEDICAL INS AEN N, INC. <br /> 1731 Howe Avenue,Suite 248 Sacramento,CA 95825 <br /> 4,t 24 Hours (916) 441.2287 <br /> HOSPITAL Ic—St. ' LOCATION CLI,ue.4— DEVIC <br /> MANUFACTURER MODEL SERIAL NO. <br /> PROBLEM: HOSPITAL CODE <br /> LOCATION CODE <br /> �- �- BEC NUMBER <br /> �sw ANALYSIS CODES 4 2 b 8 <br /> TIME ALLOCATION <br /> DISPOSITION <br /> LAG <br /> r MALFUNCTION ('54CI W) <br /> SOLUTION: <br /> ELECTRICAL SAFETY TESTS AND LIMITS <br /> CHECK®TESTS PERFORMED <br /> 1)<VISUAL CHECK S=lc <br /> ELECTRICAL <br /> 2❑OUTLETS)8 oz. <br /> C, j ENVIR M€ L <br /> 3❑CMECK)1"rtv <br /> ❑ ❑ <br /> PATTEN INTRA I60N <br /> PATIENT CAWOIAc PA'IVN <br /> ENT <br /> GROUnO <br /> Weals- 0.1512 0.15 R 0.15 12 <br /> 4 A TA.Ce <br /> 5 [X cKwssls 100 Ua 100 ua 500 ya Z <br /> lQ Lew KwGe <br /> 6 EleLecTWooe 50 ua 10 ua NA <br /> LeAKAGe <br /> INPUT <br /> 7 ISOLATION NA 10 ua NA <br /> 84PERFORMANCE TEST � <br /> FOLLOW-UP ACTION REQUIRED ALL TESTS WITHIN LIMITS YES>k <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 /> SERVICED <br /> CUSTOMER DATE <br /> SIGNATURE <br />