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NOV. 5. 2010 9:21AM DATE: DER Compllance r'omi " Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NO. 6184 P. 2 L � NOTE: Use one form for each Dump or multiple pumps on 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 115054.1 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 priorto construction or remodel. Facility Name: r Facility Address: Pool Owner Name Owners Address City Pool mnstructed on or after January 1, 20101: 0 Yes &To (if more than 1 pool/spa at sit ): St Zip: q.5'3 7G efs Phone Number Zip WPum Informatibn ecirculationPy�rtp) ❑Jet/BoosferPump Make/Model ffitV.rorri ,t/./i ��./` H.PMake/Model ❑ Other Pump: H.P ❑ Feature Pump MakelModel H.P Make/Model H,P Main Drain Includes All Suction OutletliExceDt Skimmer Equalizer Lines Manufacturer of approved dra cover. Model Number..—install date, GPM rating: Floor Wall - Installed on WF(dor 0 Wall Manufacturer of approved drain cover, Model Number, Install date GPM rating: Floor Wall Installed on E3 Floor ❑ wall Main drain/Jet suction pipe sire is � inches. Check Oil , , Milt 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) 0 Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agency) mr-__Tje of secondary device Installed: Instal[ date turer of approved device: release system bears the Model/Part performance standard markings: o ATSM F2387 0 ASMEIANSI standard A 112.10.17 tuanzer uneU , r of approved suction fitting: .&Atowt Model Number. , /fit--A?&17lnstall date GPM rating: Floor_ dol wall AJZ Installed on ❑ Floor ❑ Wall were found to be Number of 1 hold an active California State Contractor license # i r1 with classification or a California State Engineer license 0 with qualified experience working on public swimming pools and that the information ve is true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential don at the discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Company Name: Company Address: / - Cay: C _ State: ContraotodEngineer horse Number. ao&c3 Cell Phone Number: Cogin er FAX Number: con gin Contractor I Engineer name (PRINT) Fora oompk:te text of the law, visit http://Info.sen.ca Zip Code: name (SIGNATURE) Date 001.1050/ab_1020- bur _2DO91011 ehaitered.ocif ROVM. J* 14, 2010