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<br /> I"ap4ROV50 BY,, Cal'domla Departrnent of PutiftE NeOttti 2MU u6E� ?J Y
<br /> •Cwmp1ltn0t Form
<br /> Anti•Entrspthent EMviooa and Systems
<br /> MATE. far PUbflt Poets and Spilt
<br /> — -- - Notht and Safety Code Soct'ions 116064.1 end 116054.2
<br /> NOTE:Us4 one farm for Paan,_,uuroo Or pijWab cumds under It Brain Sorer,
<br /> Ali..SECTIONS Or THIS FORM MUST BE C0METED.
<br /> not lore Is to es uead t0 v4tNy eomptanet with M041mcairons partuaht to the now Health and.Safety Colo teetiont 116064 t ntnd
<br /> I 9A.2 Under Section 116064](*)of ttw Ir"th end Sefaty Code,affective Jsftusry 1.2010- tho owner of a public t:wimm Ing past
<br /> ' stmil glo this form wtNn 30 days followtno .the comptetlon of construction or inertepotion of enllvntrapmonl d0icoe.4r Cyaterns to
<br /> swrmmiwo pants. Contact your local Efty1wMentsl Health Department and Sufldiny BdpaRmanffor.eny hoctrsatryr Pith tppr0.at anc
<br /> oennlnpoor fownsuuttionatmmode1. /�_�,.•,•_,,,._�,,,_,,,,,_
<br /> F.to lnfofmtda't ��tl�
<br /> %ire Z y _ Pool identifcab"l ;d rod a tt�tn 5 pomoa at site) 1
<br /> sl 73sa.
<br /> w.,.tv:enu _...dry_:( .!" •;L•Z'"" . _._Own es Poorp Nu,,fter�^��'"'' •` /
<br /> . wc rauess _ _t L�oS_ 1��_�f..Y"-� L�cat _ � 1c(t b�rJ St A- .ha Ste_/t .
<br /> »w mnstvnr_`M ar a9er January 1,20101 'E: Yes (/Nc
<br /> �.�,,rntorma ion '
<br /> Reatrae1a11arh Pu 0 Jet.!600storpump
<br /> 1 _r ✓.Z_._,..H P,;, MavefMa?d,
<br /> Otoor Pump: 0 Fretum Pump
<br /> ':,"i+t.fradf.7��H P _— MdW4000Pt
<br /> _41�2PCciudvf At Suct•on Dunatt Ey!!at I r r_ - rvr_na} `A/it_D FGO
<br /> . I• bow crspprov r4 n cover. "t.� 0✓_j_Mdde1 NurnYser: _•InattM dint r 'Z//of/O
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<br /> 1%'rabnq rlpn•_..,,.,,Sy.� 'Wdt_......_,._�� trMsl*a an cyn/ar 'a N:ti't
<br /> •,�,ta ..nr'c!22prond tltam cover „ ptodel Number' _ In4UC dale
<br /> • nt n,•r-p' ekw__,,,_ trJ�ll y_,,,,,,,r, lrsataieoci on of low OWES Mon cirarruuet S00..10n pipe srxo is_,,,,,,,^_wmOt
<br /> '.•,ern One:
<br /> A'r.aa 0raun4;{M:rhtntltln:/K bniwer^i tto"M,n,}YraOcIll"'yr bshan.:ed rrg tymmemrasy.piumbeCj
<br /> I S4,;2 s:v.r-U'deorsutxe(srxo end$matte mot a f um3r,Macy tanner hko to create n IeN.JM o l%.PraolvY
<br /> '] Sirpw d'sm-Not unb1IO`5UIh4 (orw of int'fd&wn secondary domom mWired solely vacuum Weise 9Ystnm cocoon emrnrg vm%
<br /> rrstr'n.panty tlt'un,e system•auto o;rmp ppA gn system.or amtr equsay or lion e!'4dtna system approved Ev eMarctrmenr agora
<br /> 'gm c1secOnda'r dih1W elV440
<br /> k?a:+u:i.Lrttr at 20woved aevdi:
<br /> 5•eR•Yy#o,'.on*&ysiam beam the fo*mn4 parfarmwmoswtard rrmA,ng4-Q ATSM f2361 cYASM6JANSI VwidniCA 41219 t' ®a
<br /> - 14 mmy+r�C11etR¢r Lin41s) �•
<br /> Lrr:•ra GJe�or I�j.YrAMld sualcm ROO � maduN;"r _ L�_,--- ` r0
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<br /> .M.t ryt'y OrM nninq Fdeer_� 'fiiA„��R 2'' - Untd6od an L'.t laar W'9,r(61
<br /> ,... ^her acuah�xer ery(sr p:M ons ware loun6 o} 7.. xtCrtts Nunttor or Skurmem
<br /> + �F Awpi�Nhs REEK f1E1 qitrt_l To Cp Y fi1U %haAQuRE,FVS iNSIAU-61I4H$ UL ,MLN�S EY THr� -1t6T r
<br /> Oermre t^«I odd on trctwe CoNlom,t Stet”Cpr4rac'or bcense a $R?-1 ct Cs vMn cfn5s•6eoton C S`3_,or t Cs!damw Sn:^
<br /> no:EM'r.yrrr pools too inet IM 0144 4a••
<br /> v . •J ow"A Nb m 04 twit of my nnpwhtdge 1 urrdervap,%I.nal d I improperly 0amfy Via mf*tm9t:0n,101111 be SAW to polenbsl
<br /> *em,of the dxtotgnof II!"*�4o+J�n�S.q a�t,'y1hG�:R}"moi trctordlMtOt w'i,•1 CaUtarma H_e�h 7$Ss(Ei1'CCd6$c4,:ign�11�18C,6y.{.2�.
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<br /> r,.gr'ror.er.Eng rM"r name( rtiN)i COnasCbr(tnpmets no 1b1vNA1UREJ Owe
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