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05/1S/2011 10: 30 5376599 PAGE 04/05 APPROVED BY: ftrnia Department of Public HeAk> OFFICE USE ONLY Compliance Form DATE: Anti-Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 (/ NOTE: Use one form for each sump 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 section 116064.1 and 116064.2. Under Section 116064,2 (a) of the Health and Safety Code, effective January 1, 2010, the owner t a public swimming pool shall file this form within 30 days following the completion of construction or Installation of ant entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and 9ulldln Department for any necessary plan approval and permits prior to construction or remodel. woNt � Site Information Facility Name!.-1 W iN AK-bOV3 Pool Identification(N more than 1 pool/spa at site): C9" Sf aS FacilityAddress: 100 S H City: 1 od St: CA_zip: Owner Name: WAi Owner's Phone Number; Owners Address City St.—Zip Pool constructed on or after January 1,20107: 0 Yes Z"No RMLLfgMation Recirculation - Pum0N7 ykI( 0H.P jet/Booster Pump Make/Model Make/Model —H.P ❑ Other Pump: ❑ Feature Pump Make/Modol H.P Make/Model H.P Aain Drain Includes Ail Suction !)ptipt4 Except Skimmer Equalizer Lines / Aanufacturer of approved drain cover; A 4VAr $+air _Model Number: a MDPLli if install date $+ 17 1 ;PM rating: FloorlotWall ftZ6.. Installed on /Floor ❑ Walt Aanufacturer of approved drain cover: Model Number: Install dale ;PM rating: Floor Wall Installed on lour P_fWall Main drain/Jet suction pipe size is inches. :heck One: Split main draln(s)(Minimum 3 ft. between covers,hydraulically balanced and symmetrically plumbed) Ingle drain-Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) ❑ Single drain-Not unNockable (one of the following secondary devices required: safely 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 agen Type of secondary device installed: _Install date Manufacturer of approved device: Modell/Part Number: Safety vacuum release system beers the following performance standard markings:a ATSM F23B7 O ASME/ANSI standard A 112.19.17 THE ABOVE HAS EEN FIELD VERIFIED TO COMPLY WITH MANUFA T ER'S INSTALLATION REQUIREMENTS B T T LLE I declare that I hold an active California State Contractor license ft !a 0" with classification C--,S-3 or a California State Professional Engineer license p with qualified experience working on public swimming pools and that the information provided above is true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disciplinary action at the discrerw of the licensing authority in accordance with California Health & Safety Code Section 116064,2. Contractor/Engineer Name: Raul C440le7 SWf Company Name: eu,Ee.n �o4ufJ Company Address: 5x00 /1104S;V%54'V' City: r State:. C,A • Zip Code: 91-307 Contractor/Engineer Phone Numbeni ndoq/ 53 7-US-oo Cell Phone Number: 01 I Y9.r-xli Contractor/Engineer FAX Number: Email: r b I .&poi Contractor/Engineer name(PRINT) Contractor/Engineer name(SIGNATURE) Date For a complete text of the law,visit: http://Info.sen.co.gov/pub109-10/blll/asm/ab_1001-1060/ab_1020 bill_20091011 chaptered.pdf RETMW COMPLETED FORM TO , ENVIRONMENTAL ME MANAGENT DEPARTKENT, COUNTY OF SACRAMENTO, 10590 ARNSTRONO nvENVE MATNER CA 95655 Phone: (916) 874-60101 Pefc; (916) a74-6925; w .emd.aectouaW.net