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05/18/2011 10:30 537659 PAGE 05/05 <br /> APPROVED BV OFFICE USE ONLY <br /> INSTALLATION CERTIFICATION Fele Paid$ <br /> VGB DRAIN COVER&SECONDARY DEVICE FA: <br /> DATE: PR: <br /> NOTE; Use one form for each pump or multiple pumps under the same cover. SR. <br /> For the property named 11014 Azov, Date: <br /> located at JgD0 ff0+cWn1r , California, I hereby certify that pursuant to California <br /> Slate Health&Safety Cade Sec. 116064.1 and 116064.2, that an Anti-entrapment cover meeting the current standards of the American Social <br /> of Mechanical Engineers(ASME)/ANSI performance standard and where required,a secondary safety device meeting the current ASME/ANSI <br /> or ASTM performance standards have been installed per the manufacturer's Instructions on the: <br /> Cl ' Swimming pool ❑ Spa Recirculation <br /> Spa Jet/Booster p WadingJtoddler pool <br /> Existing Pump(s):Make/Model_Pop tir I(¢0 H.P 3OP ;Flow(ppm) <br /> Make/Model H.P ; Flow(gpm) <br /> Main Drain(s): <br /> Manufacturer of approved cover, 42L &Pnf <br /> Model/Part Number: 3A CO FLFR-la! GPM rating: Floor. n ;Wall_Installed on Aall w4or <br /> Cover bears the following markings; <br /> ❑ "VGB 2008 or later", <br /> "ASME/ANSI slanda 9 112.18.8.2007 or later", "Life": <br /> Main drain/Jet suction pipe size is I f.? inches. Manufacturers main drain(s)sump depth requirement In inches is; <br /> ❑ Single drain-Not unblockable (one of the following secondary devices required: SVRS/Suction limiting vent/gravity drainage/ <br /> auto pump shut-off/other approved by enforcement agency) <br /> o Type of secondary device installed: <br /> o Manufacturer of approved device; Model/Part Number: <br /> SVRS bears the following markings: <br /> O "ASTM F2387", <br /> 0 "ASME/ANSI standard A 112.19.17", <br /> NOTE; If Installing a variable speed SVRS pump a RPM/Time Data sheet shall be faxed to EMD at 575.8513 foilowin <br /> the installation. (A sample form is available from the Environmental Health Plan Review office) <br /> ❑ Single drain—Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) <br /> Dual main drain(s) <br /> Equalizer ling(€; <br /> Manufacturer of approved cover:. AQOR 564w "T <br /> Model/Part Numbor 3aC43FLFAIoI GPM rating:Floor-Z(J;Wal l_2Otlnstalled on o Wail a Floor <br /> p "VGB 2008 or later', <br /> z� "ASME/ANSI standard A 112.19.8-2007 or later', "Life <br /> Skimmer equalizer ins(s)pipe size were found to beIt1_Inches #of Skimmers: <br /> Manufgcturer's skimmer equalizer line(s) sump depth requirement In inches is: <br /> 2f Single equalizer line <br /> ❑ Dual Skimmer equalizer line(s) sump depth._Inches <br /> ❑ Skimmers are connected with single line to pump, SK.o",%cZ F•9, <br /> * Skimmers are separately valved before pump and can be isolated, <br /> I.ne p[Q 3Cff Ccvesco <br /> X"I declare that I hold an active California State Contractor license# SIOR 7 or California State Professional Engineer license# <br /> -S-1 with qualified experience working on public ewlmming pools and that the information provided above Is true to the be; <br /> of my knowledge. I'm aware that improper certification of the above information shall be subject to potential disciplinary action at the <br /> discretion of the licensing authority. <br /> L2W H Mar1.1 srl,el,� <br /> Signal re / _ Print name Date <br /> Contact Name: Sr A PhoneL0,09 S37&tToo email Xtw <br /> PAYMENT DUE PRIOR TO APPROVAL CALL PLAN REVIEW AT(916) 874-6010 <br /> For a complete text of the law,visit: <br /> h p,ltlnfo.son.citgov/pub/0910/bill/asm/ab 1001 10501ab 1010 bill 20091011 chantored odf <br />