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APPROVED BY DATE: NOTE: Use one torm for For the property named LARwe INSTALLATION CERTIFICATION VGB DRAIN COVER & SECONDARY DEVICE or multiple pumps under the same cover. OFFICE USE ONLY Fee Paid $ FA: Date: located at it b,/f(aKrLN.tUkL Ctr' S4-4:e.60k , California, I hereby certify that pursuant to California State Health & Safety Code Sec. 116064.1 and 116064.2, that an Anti -entrapment cover meeting the current standards of the American Society of Mechanical Engineers ASME/ANSI standard A 112.19.8-2007 and where required, a seconds safe the current ASME/ANSI or ASTM standards will be installed per the manufacturer's instructions on the: L k (e rSL Swimming Pool ElSpa Recirculation F ❑ Spa Jet / Booster ❑ Wadingltoddler pool Existing Pump(s): Make/Model H.P ; Flow(gpm) MakelModel H.P ;Flaw(gpm) Main Drain(s): 1 Manufacturer of approved cover. �ar tvv`o y 1,t� Model/Part Number. 'SDX GPM rating: Floor ; Wall_ Installed on o Wall ❑ Floor Cover bears the following markings: �❑.{ "VGB 2008 or later, "ASME/ANSI standard A 112.19.8-2007 or later, "Life": ) t�✓y Main drain/Jet suction pipe size is Q-- inches. Manufacturers main drain(s) sump depth requirement in inches is: _ ❑ Single drain — Not unblockable (one of the following secondary devices required: SVRS / Suction limiting vent / gravity drainage / auto pump shut-ofll other approved by enforcement agency) a Type of secondary device installed: o Manufacturer of approved device: ModellPart Number. SVRS bears the following markings: ❑ "ATSM F2387', ❑ 'ASME/ANSI standard A 112.19.17', NOTE: If installing a variable speed SVRS pump a RPM/TIme Data sheet shall be Taxed to EMD at 87"513 following the installation. (A sample form is available from the Environmental Health Plan Review office) D Single drain — Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) Ae Dual main drain(s) Eaualizer line(s): /I Manufacturer of approved cover. � V0.S`Wi ModeliPart Number. &HPle( GPM rating: Floor ; Walll9 Installed on Mail o Floor ❑ "VGB 2008 or later, ❑ . 'ASME/ANSI standard A 112.19.8-2007 or later, "Life': Skimmer equalizer line(s) pipe size were found to be _inches # of Skimmers: d' Manufacturers skimmer equalizer line(s) sump depth requirement in inches is: X, Single equalizer line ❑ Dual Skimmer equalizer line(s) sumpdepth inches ❑ Skimmers are connected with single line to pump. ❑ Skimmers are separately valved before pump and can be isolated. ❑ 1 declare that I hold an active California Stale Contractor license # '5/ 0 5 or California State Professional Engineer license # with qualified experience working on public swimming pools and that the information provided above is true to the best of my knowledge. I'm aware that improper certification of the above information shall be subject to potential disciplinary action at the discretion of the licensing authority. &t� N�L- ONKS Work el- 93 -/1-- Signature Print name Date Contact Name: 5A Phone;1-y30-7T-46 email 6ttvi �/4Ja✓d soars _4(A (noO1 CO.'v PAYMENT DUE PRIOR TO APPROVAL CALL PLAN REVIEW AT (916) 874-6010 For a complete text of the law, visit: hfp://info.sen.ca.gov/pub/09-10/bill/asm/ab 1001-1050/ab 1020 bill 20091011 chaptered.pdf Rev.Eele: WlWI04:16 WMM.WORMSARCHNE HOWOFS FOR ONLINEIPLAN REVEw0e10301nalel Cad Mh foes info Revised 061010.6oce