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APPROVED BY: ifornia Department of Public Hea 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 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 sections 116064.1 and 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool shall file this form within 30 days following the completion of construction or installation of anti- entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information Facility Name: r - - _ Pool Identification(if �Zore than 1 pool/spa at site): S Facility Address: Z—' Z g v h�a o div City: '" d / St:LL zip: f_�l e/zq Owner Name: Owner's Phone Number. Owners Addressity St._Zip Pool constructed on or after January 1,2010?: ❑ Yes o Pum -anon ecirculation Pump // Jet/Booster Pump Make/Model O�/12 .Aa l; -Gi�;fn a H.P Make/Model Nl - H.P� ❑ Other Pump O Feature Pu Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outlets Except Skimmer E ualizer Lines) .� Manufacturer of approved drain cover: Mod /m tuber: ;-,o JInstall date GPM rating: Floor 2z!2 11 Installed on ❑ Wall Manufacturer of approved drain cover. Model Number. Install date GPM rating:Floor Wall Installed on 0 Floor ❑Wall Main drain/Jet suction pipe size is inches. Check One: geg-plit main drain(s)(Minimum 3 ft.between covers,by lically balanced and symmetrically plumbed) ❑ Single drain-Unblockable(size and shape that a human bo nnot sufficiently block to create a suction entrapment) O Single drain-Not unblockable (one of the following secondary de required: safety vacuum release system, suction limiting vent system,gravity drainage system,auto pump shut-off system,or other eq or more effective system approved by enforcement agency) Type of secondary device installed: Install date Manufacturer of approved device: odel/Part Number. Safety vacuum release system bears the following performance standard markings:0 ATSM F23 1�ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license#�/Pe7Z,1 ,P with classification C- / or a California State Professional Engineer license# 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 discretion of the licensing authority in accordance with California Health&Safety Code Section 116064.2. Contractor/Engineer Name:�YL)-ri�isliJ 4; >zrh.o Company Name: Company Address: City: rz/c � r�1t State: �' _Zip Code: , Contractor/Engineer Phone Number: Cell Phone Number: //�� 9/-? - Contractor/Engineer /3 -Contractor/Engineer FAX Number: Email:�'r •4FE A-31 • CW44 `Y�09ilcici� •4 Yom'/�-PG�a �! -__ /�e_�r t.Zi�—�//!3 Cngineer name(PRINT) Contractor/F1lgineer name(SIGNATURE) Dale Fora complete text of the law,visit: http://info.sen.ca.gov/pub/09-10/bi[Uasm iab_1001-1050/ab 1020 bill 20091011_chaptered-pdf