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� . .. . Compliance Form • nti-Entrapment Devices and Systems DATE: for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE:Use oneform for each pump or multiple pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and 116064.2. Under Section 116064.2(a)of the Health and Safety Code, effective January 1,2010,the own"of a public swimming pool shall file this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information /�, Facility Name:6r r 12V_<6if D'.�6 rn�f�-t(� Pool Identification(if more than 1 pool/spa at site): Facility Address: 530( �CA°?ftitT tc.Iii.t,r-- br ity. 57700 C_rOAl StCk-zip: Q $Z/9' Owner Name:— C-,AnQ d1 C n I Owners Phone Number Owners Address City SL_tip Pool constructed on or.after January 1,2010?. ❑ Yes ❑ No Pump information Ll Recirculation Pump at f Booster Pump, 1 /� \y Make/Model H.P Make/Model eA-)Ila:r W Pe Q H.P [+ ❑ Other Pump: ❑ Feature Pump Make/Model HP Make/Model FLP Main Drain Includes All Suction Outlets Ea Skimmer E ual'lzer Lines X Z Manufacturer of approved in Cover. Model Number. !/ Install date (.�/�/ GPM rating:Floor Wall Installed on 04or Cl Wall Manufacturer of approved drain cover. Model Number. Install date GPM rating:Floor Wall Installed on O Floor ❑Wall Main drain/Jet suction pipe size is inches. Check One: JF4plit main drain(s)(Minimum 3 ft.between covers,hydraulically balanced and symmetrically plumbed) ❑ Single drain-Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) ❑ Single drain-Not unblockable (one of the following secondary devices required: safety vacuum release system,suction limiting vent system,gravity drainage system,auto pump shutoff system,or other equally or more effective system approved by enforcement agency) Type of secondary device installed: Install date Manufachirer of approved device: ModeWart Number. Safety vacuum release system bears the following performance standard markings:O ATSM F2387 O ASMFJANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: Model Number. Install date GPM rating:GPM rating:Floor Wall Installed on ❑Floor O Wall Skimmer equalizer line(s)pipe size were found to be inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license# �d/6�D with classification�' -or a California State Professional Engineer license# with qualified experience working on public swimming po- oYsl-nd that the information provided above is true to the best of my knowledge. I understand that if I improperly certify this information,1 shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health ASafety Code Section 116064.2. 1t ContrectorlFsginearNeme: /U r Company Name: r Company Address: �r City: State: ( ,4 Zip Code:._ Contractor/Engineer Phone Number. Cell Phone Number. Contractor/Engineer FAX Number. 6 Contractor/Engineer name(PRINT) ontror/Engi eername S NATO Date For a complete text of the law,visit httpJfinfo.sen.ca.govlpubl - i' m/ab_4001-10 /a 1020 bill_20091011 ehapte .pdf Rev N:Jdr 14,2010