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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 -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 nn Facility Name: �H& YC�L Pool Identification (if more than 1 pool/spa at site): Facility Address: /31 5. A44eAl Gk. City: 4040 St: !Q+ zip: 9rz5c2— Owner Name: 1146d27J4,J A Pemoor, Owner's Phone Number: Z01 -71Z — 06S-8 Owners Address M •7 6} u,&a D/!. City LOGS St. et- zip 4krl Pf Z, Pool constructed on or after January 1, 2010?: ❑ Yes pilo VPu Information Recirculation Puy� ❑ Jet / Booster Pump Make/Model Pur c' �7�'C $d'RS H.P Il5 Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Manufacturer of approved drain cover. WA iplc 7 GPM rating: Floor 3ls% Wail Manufacturer of approved drain cover: �— GPM rating: Floor Wall Installed on o Floor ❑ Wall Main drain/Jet suction pipe size is % inches. Check One: ❑split 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 Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings: ❑ ATSM F2387 o ASME/ANSI standard A 112.19.17 Mod .0 Number. 64199 417z K✓Install date Installed on WFloor ❑ Wall Model Number: Install date Skimmer Equalizer Line(s) N Manufacturer of approved suction fitting: rating: GPM rating: size were found to be State Contractor license # Model Number: Installed on ❑ Floor ❑ Wall Number of Skimmers: with classification date a California State Professionakw& V with qualified experience working on public swimming pools and that the information provided above is trust of my knowledge. I understand that if 1 improperly certify this information, I shall be subject to potential disciDlinary action at the discretion of the licensing authority in accordance with California Health 8 Safety Code Section 116064.2. Contractor/Engineer Name: Company Address: �f/! City: Contractor/Engineer Phone Number: Contractor/En meer FAX Number. Contractor/En ArU.113„I Contractor / Engineer name (PRINT) For a complete text of the law, visit: http:/linfo.sen.c: Company Name: W1V&Z /4/17 '"we— CA Zip Code: 71I "rZ Phone Number: e0a / 199/ name (SIGNATURE) Dat i01-1050/ab_1020_bill-20091011_chaptered.pdf Revis July 14, 2o10