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11/01/2010 07:59 5376599 PAGE 02/05 APPROVED BY: California Department of Public Health OFFICE use ONLY .Compliance Form Anti -Entrapment Devices and Systems DATE: for Public Pools and Spas Health and safety Code Sections 116064,1 and 116064,2 . NOTE: Use one form 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 owner of a public swimming pool shall file this form within 30 days following the completion of construction or Installation of anti-entrapmant 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 Informat o Facility Name: a Pool Identification (if more than 1 pool/spa at site): Facility Addresa: pr City: :�4=kl2a St/: �, Zip: S f Owner Name: �1�.�1�.a�e_- �1 ✓ .`So 1h `.J P+_cY' Co-owN<rowner's Phone Number. AOR ) Sl t —' oft✓' Owners Address /2Zn _� M,,,1Lr , G r City '&&'d d etet _ St (a, Zip 9 5 337 —6 7:2, Pool constructed on or attar January'1, 20107: LY -Yes O No Pump InTprmation Recirculation PyMP ❑ Jet I Booster Pump MakelModel _,/�I e -_ H.P� Make/Model H.P O Other Pump; o Feature Pump Make/Model H.P Make/Mplel H -P Manufacturer of approved drain cover.. ,� ,,,,�- Model Number: _ 5 O X Install date GPM rating: Floor,400. V VL% Wall , _/48 a tInj„ Installed on door O W0 Manufacturer of approval dmfA cover: - Model Number. -Install date GPM rating: Floor - W*L _ installed on El Floor !Nall Main arain/Jet suction pipe size Is inches. Check one: ` O Split main draln(s) (Minimum 3 ft, between covers, hydraulically balanced and symmetrically plumbed) ❑ Single drain — Unblockable (size and shape that a human body cannot suf 1ciently block to create a suction entrapment) 10 Ingle drain — Not unblockable (one of thefollowingfollowing secondary devices required: safety vacuum release system, suction IIm01ng vent system, gravity drainage system, auto pys am, or other equally or more effective system approved by enforcement agency) Type of secondary device Installed: Install date `7— !h _ ,0 Manufacturer of approved device:lJo,4-4r Model(Pari Number: Safety vacuum release system boars the following performance standard markings:$2(ATSM F2367 ❑ ASME/AN51 standard A 112.19.17 Skimmer Equalizer Llnels) Manufacturer of approved suctlonlfitting: JJa51✓ Model Number; Install data GPM rating: GPM rating: Fldor__*;I�j`Wall` Installed on ❑ Floor ;Wall Skimmer equalizer Ilne(s) pipe size were found to be �1 ihchas Number of Skimmers: I declare that I hold an active California State Contractor license # _ jjl Orad 7 with classification �"or a California State Professional Engineer license # with qualified experience working on public swimming pools and that the information provided above Is true to the beat of my knowledge. I understand that If I Improperly certify this Information, 1 shall be sub)ect to potential disciplinaryaetlon at the discretion of the licensing authority in accordance with California Health & Safely Code Section 116064,2, Contractor/Englnear Name: Company Name; A0Lt L6pA4 POOL (Y nn �to� Company Address: �.C� Fai�la I-,�rn,.o �A City; te/'Ca _ State: (a ZIp Cada: 4530 7 Contractor/Engineer Phone Number:1 �37 ConC�r/Engineer FAX Number: t� co_ Contractor/ nglneer name (PRINT Por a complete text of the law, visit: http:11 fo.sen,ca.s Cell Phone Number. RwAeed: July 11. 2010 a iJ�70 j �W