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I., I. LI. LV IV IV. I7nnl ado Joaquin t,ounty No. 0652 P. 2 APPROVED BY: DATE: ,alifornia Department of Public Heal .. Compliance Form Anti -Entrapment Devices and Systems for Public Pools. and Spas Health and Safety Code Sections 116064.1 and 116064.2 OFFIGE.USE ONLY 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 usedto verify compliance with modifications pursuant to the new Health and Safety Code sections' 116064.1 and 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January. 1, 201 D; the owner of a public swimming pool shall file this form within 30 days following the co entrapment devices or systems in swimming pools, mpletion of construction r installation of anti - Contact your local Environmental Health Department and Building Department for any necessary plan approval and permiLs prior to construction or remodel. S cility Name* n cZ Facility Name: r LI Pool Identification (if more than 1 poollspa at site): •C/cf,'c f'N/ Facility Address: 'S %L)j /Ytvfjr/il..cc�� `�.,rLL_ .. Cily: sdt�.�,rGn St yP: Owner Name; Owners Address Owner's Phone Number. 5_Zp Pool constructed on or after January 7, 2010?: O V¢S y 1. 0 Pu nformation Reclrculalion 0 Jet / Booster Pum Make/Model 7,/,y,../„-7 H,P _ p Make/Model H P ❑Other Pump' 0 Feature Pump Make/Model H,P Make/Model Main Drain Includes All Suction outlet ce Skimmer Eclualizer Lines H P Manufacturer of approved drain cover.^- A, 01 - GPM rating: Floor Model Number. Y92 ^Install dale - ' r"- Installed onoor O Wall Manufacturer of approved drain cover. Model Number; Install dale GPM rating: Floor Wall lnslalled on 0 Floor O Wall Main drain/Jet suclion Check One' pipe size is inches. frtPill in drain(s) (Minimum 3 fL between covers, hydraulically balanced and symmetrically plumbed) O Single drain - Unblockable (size and shape that a human body Cannot sufficiently block to create a suclion 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 agency) Type of secondary device installed: Manufacturer of approved device: Install date Safety vacuum release system bears the folbwin Model/Part Number: g performance standard markings:0 ATSM F2387" 0 ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER 1 declare that I hold an acllve U8100mia Slate Contractor license N Professional Engineer IifROse # 5 / with classification or a California Slate with qualified experience working on public swimming pools and that the information Provided above is vue 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 discretion of the licensing authority in accordance with California Hea 8 Safety Code Section 116064.2. Conlraclor/Engineer N e: Company Name: 4 Company Address- City:/. - Stale: (.i / Zip ContraC1002ngineer Phone Number. �� % l" - Cell Phone Number: wnn actor r tngmeer name For a complete text of the law. visit: - ^--•-•�••••�-+•.neo_rvul-nuwrab_to20_bill 20D910t1_chaptered.pdT Ct�ta1,DARD