Bulk Oxygen Site Survey Form

Instructions for use: This form is to be used for prospective or new (permanent or temporary) Messer bulk storage installations, major modifications/upgrades, and for customer or competitor owned equipment where Messer will supply product. For medical accounts: If Messer will supply product to existing equipment or an Audit Report is required, a Retrospective Validation form and PM Inspection form must be completed. For industrial accounts: If Messer will supply product to existing equipment, a First Fill Inspection form must be completed. This form may also be used for Nitrous Oxide sites. Note: This form uses safety distances found in CESCOM-ST-0001 & NFPA 55-2020.

"*" indicates required fields

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Customer Information (This section should be completed by Sales)

Customer Type*

New Customer

Existing Customer

Distributor Site

Check all that apply

Company Name*

Customer Phone

Customer Contact Name

First Last

Distributor Name

Installation Address*

Street Address City State ZIP Code

Messer Account Manger

Account Manager Email

Delivery Access Hours

Production Shift Hours

# of Shifts

Days/Week

Site Details

Projected Daily Usage

Usage Measurement

SCF

GAL

Product

LOX

Industrial

Medical USP

Other

Avg Flow Rate

Average Flow Rate Volume

SCF/H

GAL/H

Peak Flow Rate

Peak Flow Rate Volume

SCF/H

GAL/H

Customer Line PSI

Max/Min Temp (F)

Future Expansion Plans Year

Usage Increase

Site Layout Image

Accepted file types: jpg, jpeg, png, gif.

Equipment Sizes

Main Tank Size

Main Tank Orientation

Vertical

Horizontal

Reserve Tank / Cylinders Size

Reserve Orientation

Vertical

Horizontal

Ambient Vaps Size

Ambient Vaps Qty

Powered Vaps Size

Powered Vaps Qty

Switching

Seismic acceleration (Ss) of Customer Location

0-15%

15-30%

30-50%

>50%

Other

Customer Owned Tanks

MAWP

N.B. #

Yr. of Manufacture

Tank Manufacturer

S/N

Tank PSV #1 Test Date

MM slash DD slash YYYY

Tank PSV #2 Test Date

MM slash DD slash YYYY

Telemetry

Communication

Wireless (Service Avail)

Wireless (Service Limited)

Wired (Phone Req'd)

Other

Power

110 VAC

220 VAC

Solar

Other

# of Tanks on Unit

Other

Elec Haz Loc

Yes

Other

Will a Low Temperature Shutoff/Alarm be Required? (N/A to Medical)

Yes

Other Equipment

LT1: Does or will the customer have any carbon steel gas buffer vessels (e.g. gas mixers, stora e/buffer tanks connected to the bulk customer station?*

Yes

LT2: Does or will the customer have any process piping (e.g. carbon steel, thermoplastic, etc) or components (e.g. valves) that are not rated for cryogenic service?*

Yes

LT2A: Will the customer station utilize powered (electric, steam) vaporizers?*

Yes

LT2B: Will the customer station utilize switching (electric or manual) ambient vaporizers?*

Yes

LT2C: Will the customer station utilize non-switching ambient vaporizers and does the system have a PV>580 psig-in?*

Yes

LT2D: Will the customer station utilize non-switching ambient vaporizers and does the system have a PV<580 psig -in?*

Yes

Section Break

LT3: Will the customer station be used for inert gas blanketing or purging hazardous process or atmosphere (e.g. tank blanketing , controlled atmosphere furnace ?*

Yes

LT4: Will there be any other adverse safety conditions created due to interruption of gas supply caused b low temperature device activation reliability of gas supply to the customer ?*

Yes

LT5: If a LTCO already exists. is it set to close at a set point no lower than -20°F? If "No" contact CES Engineering.*

Yes

LT6: If a L TCO is required, was a trim heater discussed with the customer?*

Yes

LT7: Has the hazard assessment and installation of a low temperature shut down device been discussed/reviewed with the customer?*

Yes

Customer Name

Customer Title

LT8: Was a walk-through of the customer's piping/process performed during the low temperature hazard assessment?*

Yes

LTP Hazard Assessment Notes

1. PV of the system is calculated by multiplying the maximum operating pressure (psig) by the downstream pipe internal diameter (inches). Example; Tank MAWP=250 psig, Largest downstream pipe diameter=2 inches; PV-=500 psig~in 2. LTCO: Systems that require LTCO should be equipped with a low temperature shut down device per CES standards that can be tested on an annual basis. 3. LTAP & Telemetry (optional): For stations that fall under this requirement, a low temperature alarm may be installed. The alarm should be connected to a station that is monitored by the customer and can be connected to Messer wired telemetry for additional monitoring. 4. Comments: Provide other explanation or details relative to the low temperature protection assessment.

Ill. Site Conditions - Does the site meet the following safety requirements:

A. Safety Distances (Except where noted, all distances are spherical from exposure hazard.)

A1: 3 ft from Buildinqs of Type I and II construction (Other then wood frame)*

Yes

A2: 50 ft from Buildings of Type Ill, IV, or V construction /Wood frame)*

Yes

A3: 50 ft from public assembly { > 50 people)*

Yes

A4: 10 ft from public sidewalk or parked vehicles*

Yes

A5: 5 ft from property lines*

Yes

A6: 15 ft from weeds, long grass and combustible debris*

Yes

A7: 50 ft from any open flames or welding*

Yes

A8: 8 ft from inlets of underground sewer systems to liquid delivery connections, pressure relief device outlets, mobile supply equipment, and withdrawal connections*

Yes

A9: 10 ft from nearest opening in walls or other structures*

Yes

A10: 50 ft from nearest non-ambulatory patient*

Yes

A11: 50 ft from the FATO (final approach and take-off\ area of Heliports*

Yes

A12: 50 ft from solid rapid-burning material /paper, excelsior, garbage dumpsters, etc. )*

Yes

A13: 25 ft from solid slow-burning material - coal, lumber, etc.*

Yes

A14: 75 ft from liquefied hydrogen storage*

Yes

A15: Above Ground Storage - Flammable Gas: 25 ft. from non-liquefied, dissolved gas, compressed (25,000 ft3 or less) and 50 ft. from non-liquefied, dissolved gas, compressed (over 25,000 ft3 )*

Yes

A16: Above Ground Storage - Flammable/ Combustible Liquids or Liquefied gases: 25 ft. from liquid tanks (1000 gal or less) and 50 ft. from liquid tanks /over 1000 aal)*

Yes

A17: Underground Storage: Flammable and Combustible Liquids: 15 ft horizontal distance from liquid tanks*

Yes

A18: 25 ft from vent or fill openinas to all classes of flammable or combustible underground liquid tanks*

Yes

A19: 50 ft (horizontal distance) from overhead wire of an electric trolley, train, or bus line*

Yes

A20: 5 ft (horizontal distance) from overhead electrical wire other then those noted above*

Yes

A21: 15 ft to overhead oioinq containinq other hazardous materials (e.g. flammable, toxic, corrosive fluids)*

Yes

A22: 15 ft to aboveground exposed piping and components for flammable gas systems (e.g. gas main)*

Yes

A23: 15 ft to class IIIB combustible liquids (flash Point> 200°F - e.g. vegetable oil, biodiesel)*

Yes

A24: 3 ft area, of non-combustible surface, below connections where liquid can fall during filling*

Yes

A25: Does the fill connection /i.e. extended fill connection) meet the minimum safety distances required above?*

Yes

A26: Does a protective structure having a minimum fire resistance of 2 hours interrupt the line of site between uninsulated portions of the bulk oxygen storage installation and the exposure indicated above?*

Yes

B. Foundation Pads

B1: Do the existing main & spill pads or will the proposed site have sufficient space for Messer customer station equipment installation and service clearance requirements? (Record existing/proposed size below)*

Yes

Tank Pad Length

Tank Pad Width

Spill Pad Length

Please enter a number greater than or equal to 12.

Spill Pad Width

Please enter a number greater than or equal to 12.

B2: Are existing main and spill pads concrete, level, and adjacent to one another?*

Yes

B3: Are existing main and spill pads free of cracking and spalling?*

Yes

B4: Will equipment of equivalent or smaller size be installed on the existing pad?*

Yes

B5: Are existing foundation pads of suitable thickness for the equipment intended to be installed?*

Yes

B6: Do foundation joints in pads appear to be filled with a non-combustible/LOX compatible joint sealant and are pad surfaces free of combustible and/or flammable sealants or other material?*

Yes

Pad Location & General Site Conditions

B4: Will equipment of equivalent or smaller size be installed on the existing pad?*

Yes

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