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<wiw I'i 7n1n adn Joaquin bounty No. 0651 P. 1 <br /> =IBY- alifornia Department of Public Heal.Compliance FormDFFIGE.usE NLY <br /> Anti-Entrapment Devices and Systems <br /> for Public Pools.and Spas <br /> Health and Safety Code <br /> Sections 116064.1 and 116064.2 <br /> NOTE: Use one form for each pump or multiple pumps under the same drain cover. . <br /> ALL SECTION'S OF THIS FORM MUST BE COMPLETED. <br /> This form is to be used'to verify compliance with modifications pursuant to the new Health and Safety Code ' <br /> 116064.1 and 116064.2. Under Section 116064.2 (a)of the Health and Safety Code,effective Jasections <br /> mpletion of construction or instalfnuary. owner of <br /> 1, 2010; the <br /> e pf ant;- <br /> a public swimming pool shall file this form within 30 days following the co <br /> entrapment devices or systems in swimming pools. Contact your local Environmental <br /> Department for any necessary plan approval and permits Health Department and Building <br /> Site information prior to construction or remodel. <br /> 1 � <br /> Facility Name:1/r.^�C��,.y �x/� Pool Iden till, *on if more than 1 pooUspa at sit ): c• t��, <br /> Facilily Address: , yr, r. _ _ <br /> City: < Sf.�zip: <br /> Owner Name; <br /> Owners Address Owners Phone Number" <br /> Pool constructed on or after January 1,20107: —City7/jp❑ Yes fYt7 <br /> 0 <br /> Pu nformalion <br /> Recl I- N•i <br /> MakelModel t •/>OdCH.P O Jet/Booster Pump <br /> 5✓ <br /> ❑ Other Pump: Make/Modell H p <br /> MakelModel O Feature Pump <br /> H.P Make/Model <br /> Main Drain fincludes All Suction Outle Exce Skimmer Equal;-­ :- - H P <br /> Manufaclurerof appr�o)ved drain cover „7-�,,,_;;c y- <br /> GPM rating:Floor 4pc" Model Number.' .-r!/j Install date <br /> Wall Installed on RoP p r 0 wall <br /> Manufacturer of approved drain cover: �f✓ . <br /> GPM rating: Floor 'ca Cl Vy Il Model Number: /� Inslall date , <br /> Check One: �� a '�y" Installed on O Floor 6ITa'11 Main drairdJet suction pipe size is <br /> inches. <br /> a_iplil main drain(s)(Minimum 3 It between covers,hydraulically balanced and symmetrically plumbed) <br /> 0 Single drain—Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) <br /> 0 Single drain—Not unblockable (one of the following secondary devices required: safety vacuum release system,suction limiling vent <br /> system,gravity drainage system,auto pump shut-of system„of other equally or more effective system approved by enforcement agency) <br /> Type of seconclary device installed: <br /> Manufacturer of approved device: Inslall date <br /> Safetyvacuum release syslem bears the followingModel/Part Number: <br /> pstandard markings:o ATSM F2397 0 ASME/ANSI standard A 1121917 <br /> THE ABOVE HAS BEEN FIELD VERIFIED TO COOMPLYMPLY WITH ANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER <br /> I declare that I hold an active California Slate Con"Clor license q , <br /> Professional Engineer license# S with classification _� or a California Slate <br /> with qualified experience working on public swimming pools and[hal the information <br /> 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 <br /> disciplinary action at the discretion of the licensing authority in accordance with California Health 8 Safety Code Section 116064.2. <br /> ConuaClor/Erigineer N e: Company Name: G� �f O/J c•c <br /> Company Address: ) <br /> City: - <br /> Stale: Zip Code: C.""7 �,.5? <br /> ContraclOr/Engineer Phone Number. <br /> Cell Phone Number: <br /> co foC r/Engineer F Number: <br /> � <br /> Jilin <br /> l Em '. <br /> Contractor/tngineer name(PRINT) Cvntrac r ngineer name(SIGNATURE) l <br /> For a complete lex[of the law,visit: http:l/Info.sen"ca.govlpub/09.10/bilUasm/ab_1001-c& <br /> -bill 20091011 chaptered.pdf <br /> l �� <br />