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APPROVED BY: DATE: California Department of Public Health Compliance Form Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 OFFICE USE ONLY NOTE: Use one form for each pump or multiple Dumps 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: CeoetN u �exk AvkS Pool Identification (if more than 1 pool/spa at site): you Facility Address: -2yo3 l Lo • 5,.,a.�y. rot City: S-FoclC-toV\ St: CZip: g5-z-Iq Owner Name: _ Owners Address Pool constructed on or after January 1, 20107: ❑ Yes X No Pump Information ❑ Recirculation Pump Make/Model H.P ❑ OtherPuml Make/Model Owner's Phone Number: St. _ Zip ❑ Jet/ Booster Pump Make/Model H.P ❑ Feature Pump Make/Model H.P Manufacturer of approved drain cover: AAutLSIro-r Model Number: 3Z4!AFLFf-MXInstall date S-Zt-1'i GPM rating: Floor 2 r+ Wall \Z2g9M Installed on Floor ❑ Wall Manufacturer of approved ain cover: —� Model Number: Install date GPM rating: Floor Wall Installed on ❑ Floor 0 Wall Main drain/Jet suction pipe size is inches. Check One: ❑ Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) Single drain -Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) ❑ 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: Install date Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings: D ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer Equalizer Llne(s) Manufacturer of approved suction fitting: AQ Model Number: P& e��&4 Install date S- Z4- ( 3 GPM rating: GPM rating: Floor �i Wall Z �,. Installed on ❑Floor �[ Wall Skimmer equalizer lines) pipe size were found to be ��inches Number of Skimmers: i 3 I dec at I hold's a Calffornih State Contractor license # %k Own with classification C_-53 or a California State Profe al'Epginee I se # with qualified experience working on public swimming pools and that the information p Sbgve,l5 tfiu "est 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:VDW CUSTO►n IENT SNC Company Name: CUSTOM TOOT. FLprsite%No Company Address: 52vo rA City: Nrc" State: CA Zip Code: '15307 Contractor/Engineer Phone Number 20 f1 l' (,500 Cell Phone Number: (7..01 \) L(Ib - 648H Contractor/Engineer FAX Number: vg) 53-7- 6514t Email �Q AOL . rw+ G - 4 - t3rCnt\ctornagh%e (PRINT) Co tractor/ E gineer na IGNpTURE) Date For a complete text of the law, visit: httpalinfosen.ca.govl ub109-101billl /ab_1041-106f 1020_bill_20091011_chaptered.pdf