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Apr. 1/. 1UIU IU: 19AM San Joaquin County No- 0652 P. 2 <br /> APPROVED BY: Zalifornia Department of Public Heah" OFFICES USE ONLY . <br /> Compliance Form <br /> DATE: 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 SECTIONS 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 sections <br /> 116064.1 and 116064.2. Under Section 116D64.2 (a)of the Health and Safety Code,effective January 1.2010; the owner of <br /> a public swimming pool shaliffle this form within 30 days following the completion of construction or installation of anti- <br /> entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building <br /> Department for any necessary plan approval and permits prior to construction or remodel. <br /> Site {l <br /> Information ,� <br /> Facility Name: ,�,� &I Pool Identification(if mon:than 1 poovspa at si ): <br /> Facility Address: r4t City: N3=t�feL: T— <br /> sr. z;p9��' <br /> Owner Name; Owners Phone Number. <br /> Owners Address City SL <br /> Pool 0onstruZp <br /> Ged on or atter January 1.2010?: ❑ Ves <br /> Pu ormabon +� <br /> Recirculalion �" eC ❑ Jet/Booster pump <br /> Make/Model L M.PAll& <br /> _ Make/Model <br /> H.P <br /> ❑ Other Pomp; <br /> Make/Model o Feature Pump <br /> H.P <br /> Make/Model H.P <br /> Main Drain Includes All Suction Outl s Ekce Skimmer E ualizer Lines / <br /> Manufacturer of approved drain cover. Model NumberT�•Install date 14P-/.P <br /> GPM rating:Root dao Wal Installed on fbF�pQr D wall ./ <br /> Manufacturer of approved drain cover. Madel Number;Aj/?Ptnslall dale <br /> Check On <br /> GPM rating:Flop wall Installed on O Floor &Wall Main drain(Jet Suction pipe size is_�inches. <br /> Split main drain(s)(Minimum 3 IL between covers,hydraulically balanced and symmetrically plumbed) <br /> O Single drain-Unblockable(size and shape that a human body Cannot sufficiently block to create a suction entrapment) <br /> O Single drain-Not unblockable (one of the rollowing secondary devices required: safely vacuum release system,suction limiting vent <br /> System,gravity drainage system,auto pump shut-off system,or other equally or more effective system approved by enforcement agency) <br /> Type of secondary device installed: I Install date <br /> Manufacturer of approved device: Model/Part Number: <br /> Safetyvacuum release System bears the following performance standard markings:o AT-SM F2387 O ASMFJANSI standard A 112.19.17 <br /> THE ABOVE HAS BEEN F%LD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER <br /> I dedare that I hold an active California Slate Conoaclor license# with eiassificalion�_or a California State <br /> Professional Engineer license At with qualified experience working on public swimming pools and that the information <br /> .Provided above is true to the best of my knowledge. I understand that if 1 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 9 Safety Code Section 116064.2. <br /> ConVaGOr/Engineer N e. Company Name-ALI iih 40 <br /> Company Addre S; <br /> City: f� Stale: <br /> Zip Code:9 a <br /> Cdntraclor/Engineer Phone Number. � Cell Phone Number: . <br /> Contra ngine r F N bet: - _- <br /> Contraflorl Engineer namePRINT <br /> ( ) Contract nglneer name(SIGNATURE) Dale <br /> For a complete text of the law,visit httpJflnfo.sen.cELgOv/PublOg-101bilVasaVab-1001-1050/ab-1020-biIL20091011 chaptered.pdf <br /> 00IY <br />