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� s 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 /' Facility Name: 01J lrf�Q ^,6/2 h[�10 ( Pool Identification (if more than 1 pool pa t site): Facility Address: g _hQ yl Ip City: �h r St:—(A zip:Ty�T Owner Name: Owner's Phone Number: Owners Address City St. Zip � Pool constructed on or after January 1,20109: O Yes ❑ No Pump Information ❑ Recirculation Pt Jet I Booster Pump Make/Model N/., W# H.P f Make/Model H.P ❑ Other Pump: ❑ Feature Pump i Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outlets Except Skimmer Equalizer Lines Manufacturer of approved drain cover. Model Number: .f.D 1C Install date GPM rating: Floor Zap Wall__ Installed on rloor 0 Wall ' Manufacturer of approved drain cover. Model Number: ` Install date GPM rating:Floor Wall Installed on o Floor ❑Wall Main drain/Jet suction pipe size is_Z inches. k Oe: Split main drain(s)(Minimum 3 ft.between covers,hydraulically balanced and symmetrically plumbed) O 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: Ak ftlij;^� F Model/Part Number: Safety vacuum release system bears the following perf4mance standard markings:o ATSM F2387 O ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: 4( Model Number: Install date GPM rating:GPM ratFloor � A Installed on ❑Floor ❑ Wall Skimmer equaliz pipe size were found to be inches Number of Skimmers: THE ABOV EEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I h ve California t to Contractor license# with classification or a California State _ Professional Eng se#= _with qualified ex erience working on public swimming pools and that the information providedabove is tru a best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disciplinary action cretion of the licensing authority in accordance with California Health&Safety Code Section 116064.2. Cillill T{ e Contractor/Engine V® 014r L Company Name: Company Add r ss .�j City: GEN State: _Zip Code: t� Contractor/Engineer Phone Number: �'�-� Cell Phone Number: Contractor/Engineer FAX Number: Email: e L_ ., Contractor! ngineer n me INT) ont ctor/ ine r name(SIGNATURE) Date i complete text f the law,visit: http://info.sen.ca.gov/pub Iblll/asm/ab. 1001-1050/ab 1020 bill 20091011_chaptered.pdf Revised:My 14.2010