Equipment : Anesthesia FO-20S Part Number :

Group : Monitoring Serial Number : 171820249

Vendor : ACOMA Version :

Description Serial Number Part Number Qty Check list

Unit 1 2
Anesthesia FO-20S 171820249 1 unit

Ascessories

Pressure tube for O2 5m 1 pc

Pressure tube for N2O 5m 1 pc
Pressure regulator for O2 1 pc
Pressure regulator for N2O 1 pc
Sillicone tube with canister joint 1 pc
Breathing bag 1 pc
Surplus gas Removal corrugated tube 1 pc
Spanner (19x22mm) / Kunci Pas 1 pc
Mask No. 3 1 pc
Mask No. 1 1 pc
Inspiratory valve unit 1 box
Absorber 1 pc
Manual book 1 pc

Checked by : Received by :
Date : / / Date : / /

Sign : Sign :

Page 1 FO-20S
Equipment : Anesthesia FO-20S Part Number :
Group : Monitoring Serial Number : 171820249

Vendor : ACOMA Version :

Description Serial Number Part Number Qty Check list

Unit 1 2
Anesthesia FO-20S 171820249 1 unit

Ascessories

Adult anesthesia breathing circuit reusable 1 pc

Checked by : Received by :
Date : / / Date : / /

Sign : Sign :

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