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. ., . .._ .__ .. . . __..._....— .....r.-.... „...-... ... ..v..v . ,..u,�.. urriGt uSE ONLY Compliance Form IDATE: Anti-Entrapment Devices and Systems for Public Pools and Spas X11 D Health and Safety Code JU P[� Sections 116064.1 and 116064.2 ENVI L 1 9 2010 oo L_... ROiVtIgEiUTrl NOTE: Use one form for each pump or multiple pumps under the saRRkTlin 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 secfl? 116064.1 and 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owne a public swimming pool shall file this form within 30 days following the completion of construction or installation of entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Build Department for any necessary plan approval and permits prior to construction or remodel. Site Information Facility Name: �e,'Q�IAS ��r'I"' Pool Identification (if more than 1 pool/spa at site): _ Facility Address: 312A KCity: Q-00k'— St: CA-Zip: Owner Name: LerC( r7 Mq, Owner's Phone Number: Owners Address PCS QOI 2j City ZipZ�.J__ Pool constructed on or after January 1,2010?: ❑ Yes No Pump Information ❑ Recirculation Pum C1 Jet/Booster Pump - Make/Model �rL LE H.P� • Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model FI.P Make/Model H.p Main Drain Includes All Suction Outlets Except Skimmer E ualizer Li�n+es Manufacturer of approved drain cover: a COK Model Number: 8Ay IOI UGBlnstall date J'-3 GPM rating: Flour Wall Installed on ❑Floor ❑ Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on '%Floor *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 von system, gravity drainage system, auto pump shut-offste F' or other equally or more effective system approved by enf�rcemenhee. Type of secondary device installed: IlAr- — (Y(— Install date 5,--' f 1 Manufacturer of approved device: V A/,=_4) ` T-N6U cT\ JF_S Model/Part Number: LIA6Q6:$V_95 Safety vacuum release system bears the following performance standard markings:❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE iNSTAI_LE I declare that I hold an active California State Contractor license 14 with classification--ZL_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. Contractor/Engineer Name: h I G U CL VAI:Zc(„a _Company Name: M I Cj:\) Company Address: 11 SU N N u O N 12 1Z p City: '�hCz C)C State: CA Zip Code: Contractor/Engineer Phone Number: 20!1 - 63u - 669a Cell Phone Number: 1.Q 1 - $/a;-75Z_045 __ Contractor/Engineer FAX Number: Email: a urs M (� t, --I- G�aacia � 10 --2010 Contractor/engineer name (PRINT) ntracto ngtneer na (SIGNATURE) Date For a complete text of the law, visit: hfp://info.sen.ca.gov/pub/09.10/bill/asm/ab 1001-1050/ab_1020_bili-20091011_chaptered.pdf