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05/13/2011 10:30 537659° APPROVED BY; DATE; ,ifornia Department of Public H�,ltrr Compliance Form Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 PAGE 02/05 OFFICE USE ONI,X 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 sectio 116064.1 and 116064.2. Under section 116064.2 (a) of the Health and Safety Code, effective January 1, 201 D, the owner a public swimming pool shall file this form within 30 days following the completion of construction or Installation of a entrapment devices or systems In swimming pools, Contact your local Environmental Health Department and Build Department for any necessary plan approval and permits prior to constructiorli or remodel. site Information Facility Name: Tiro`) A1_r ovi Poo( Identification (if more than 1 pool/spa at site): O Facility Address: shy§ P,ody-AUj City: Led '# St: L&- Zip:_M Owner Name: 9ftwi j Owner's Phone Number: 7-1.2 'QL07S/ Owners Address City 5't. —ZIP Pool constructed on or after January 1, 2010?: p Yes ZNo Oum Infer io FRecirculation Pum o Jet / Booster Pump Make/Model �Y= 4�CIl.o H.P31E Make/Model H.P O Other Pump; Cl Feature Pump Make/Model H.P Make/Model H.P Aaln Drain Includes II Suctfo lets Exc t Skimmer Equalizer Lines Aanufacturer of approved drain cover: Model Number: 32140CLF v Install date 5-1/ 71/i 3PM rating: Floor all, Wall 008 Installed on &loor 2,"Wall Aanufacturer of approved drain cover: ARL ,g&tr Model Number 3e�COPLIPM0 Install dale sJ/ 7 / 3PM rating: Floor W, Wall 208 Installed on;?Floor ;aWall Main drain/Jet suction pipe size Is It inches :heck One: ZSpllt 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) O 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 ager 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 F2367 o ASME/ANSI standard A 112.19.17 I declare that I hold an active California State Contractor license with classification C_5or a California Stale Professional Engineer Itcense # with qualified experience working on public swimming pools and that the information provided above Is true to the best bf my knowledge, I understand that if I improperly certify this Information, I shall be subject to potential disciplinary action at the discretionof the licensing authority In accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Name: ROJ Cff&M evvk P CornpanyName: casisn Lml _ Company Address: _ g -O City: CEV+CS Slate:. C-.& - Zip Code: 9.S3o7 Contractor/Engineer Phone Number: 120V 7- LOS700 Call Phone Number; CLO'/ yqr-9.7s7 Contractor/Engineer FAX Number:(Ay _sa,�_(�s'9� Email: flout Cis'Re �& m, Cprq ��&, 1114046040- LAf tPCw) s1�7/a Contractor / Engineer name (PRINT) Contractor/ Engineer name (SIGNATURE) Date For acorn plots text of the law, visit: http://Inf*.Gen.ca.govipub/09.10/blil/asm/at)_1001-1050/ab 1020_bill 20091011 chaptered.pdf RETllRN COMPLSTso PDRWTO : ENVIRONMENTAL MANAOEMEN'P DEP4RTM3NT, COUNTY OF sACRAMSNTO, 10590 AHytaTRoma AVENUE MATNER CA 95655 Phone: (916) 874-6010, Pam: 1916) 874-6025, www, emd. 0eccoun Cy,nec