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_ ,APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form Anti -Entrapment Devices and Systems DATE: 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 ® Recirculation Pump Facility Name: Pool Identification (7f more than 1 pool/spa at site): Lincoln High School pool Facility Address: City, State, Zip Code: 6844 Alexandria Place Stockton, CA 95207 Owner Name: Owner Phone Number: Lincoln Unified School District 209-915-7330 Owner Address: City, State, Zip Code: 2010 West Swain Road Stockton, CA 95207 Pool construction on or after January 1, 2010? ❑ I YES 10 1 NO PUMP INFORMATION ® Recirculation Pump ❑ Jet / Booster Pump Make/Model: Century 3 -Phase H.P. 15 Make/Model: H.P. ❑ Other Pump ❑ Feature Pump Make/Model: H.P. Make/Model: H.P. MAIN DRAIN Includes all suction outlets except skimmer equalizer lines Manufacturer of Approved Drain Cover: 4 A uastar9X9 Model Number: RWAV9101 I Install Date: 05/26/2009 GPM RATING Floor: 207 ea wall: INSTALLED ON ® FLOOR ❑ WALL Manufacturer of Approved Drain Cover: 4 A uastar 9X9 Model Number: RWAV9101 Install Date: 1 05/26/2009 GPM RATING Floor: 207 ea I wall: INSTALLED ON ® FLOOR ❑ WALL NOTE: (4) 9X9 = (1)18X18 with flow rate of 828 GPM Main drain /jet suction pipe is 6 inches Check One: ® Split main drain(s) (minimum 3 feet 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: ❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 I declare that I hold an active California State Contractor license # 930970 with classification C53 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. r/Engineer Name: Address: PO Box Phone Number: Fax Number: Sean J. Senior )r/Engineer Name (PRINT) mplete text of the law, visit: Company Name: State: IA Zip Code: 94513 Cell Phone Number: (925) 383-7923 Email: doreen@naspools.COm 6/22/2010 Name (SIGNATURE) Date