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, I - 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 116D64.2. 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 , r Facility Name: ON V14 uQ (.�h J I),( Pool Identification (if more than 1 pool pa t site): Facility Address: g�3 ,h n vt ✓�! City: St:-(AZip:q Owner Name: Owners Phone Number: Owners Address City St.—Zip Pool constructed on or after January 1,20101: D Yes O No Purnp Information Recirculation P mp D Jet/Booster Pump Make/Model i� H.P if Make/Model H.P ❑ Other Pump: D Feature Pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outlet Except Skimmer Equalizer Lines Manufacturer of approved drain cover. Model Number: .SMC Install date GPM rating:Floor �'0 Wall ITO Installed on %&loor D Wall Manufacturer of approved drain cover. Model Number: Install date GPM rating:Floor Wall Installed on D Floor ❑Wall Main drain/Jet suction pipe size is. nches. ,ck One: Id Split main drain(s)(Minimum 3 ft.between covers,hydraulically balanced and symmetrically plumbed) D Single drain-Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) D Single drain-Not unblockable (one of the following secondary devices required: safety vacuum release system,suction Ilmiting 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 andard markings:D ATSM F2387 D ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufapturpr of approved suction fitting: .UI II/ Model Number: Install date GPM rljg!�rating:Floor �I ail Installed on ❑Floor D Wall SklmrraNI her line(s)pipe size were found to be inches Number of Skimmers:—I-- VE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declot Id an active Califomia to Contractor license# with classification or a California State _ Profes�jineer license#_N�_with qualified ex 7 erience working on public swimming pools and that the information provld�rsl''s true to the best of my knowledge. 1 understand that If I Improperly certify this information, I shall be subject to potential discipliliffTINpri at the discretion of the licensing authority in accordance with California.Health&Safety Code Section 116064.2. s r Contra ear Name: _�r('V_ Roark- Company Name: Compaityfsagr ss: I City: State: [' Zip Code:` Contractor/Engineer Phone Number: /'�"- a Cell Phone Number: � ._.2.. Contractor/Engineer FAX Number: .S Email C (Q�(� ' Le R //11 Contractor/ ngineern me INT) or clot/ Ina r name(SIGNATURE) Date a complete text f the law,visit: http:ftinfo.son.ca.go.ipub /billlasm/ab_1001-1060/ab_1020_blll_20091011 chaptered.pdf Revised:July 14.201D