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4V1V I'i unlit Jdn doaquln County No. 0652 P. 2 APPROVED BY: :alifornia Department of Public Heal... Compliance Form oFFtcE.useoNLv PATE: Anti-Entrapment Devices and Systems for Public Pools.and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each pump or multiple bumps 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 116064.1 and 116064.2. Under Section 116064.2 (a)of the Health and Safety Code,effective January 1, 2D10;-tlie owner section'ss a public swimming pool shalt file this form within 30 days following the completion of construction or installation of antof i- enhapment 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: _> 'rte- .� Pool ldenOrifydion/i(more than 1 pool/spa at site Fatillty Adtlress �/ T�a-- �� Goy. /n Owner Name: StG zip:. Owners Address - Owner's Phone Number city s1._zip Pool constructed on or after January 1,2010?: ❑ Ye* la,5' Pump,11111ormalion Recirculatio Porn Make/Modelt1�//r �%��S'H� '/ ( o Jet/Booster Pump o Other Pump: Make/Model H P Make/Model O Feature Pump H.P Make/Model Main Drain Includes II Suction OuU H.P ce Skimmer E ualizer Lines Manufacturer of appr ved drain cover; w v GPM rating:Floor ` ;F— Wall Model Number R. �QIXInstall date f3 ' v17L7 Manufacturer of a �- Installed on A1•o O Wall approved Orcin cover. - bJr/�' i S pfd�' GPM rating: Floor.Well Model Number: Install dale Check One: —� - Installed on o Floor @Walt-Main drain/Jet suction pipe size i5 'n Inches O Split main drain(s)(Minimum 3 It between covers,hydraulically balanced and symmetrically plumbed) O 80' @L-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 rele"ase system,suction limiting vent system,gravity drainage system,auto mp 8 stem, Type of secondary device installed- ( "I eyregyally Or more effective system approved by enfor em t agcy) L t Manufacturer of approved device: '� Install date Safety vacuum release system bears Chef twin Model/Part Number:-z_ g performance standard markings:o ATSM F2387 ❑ ASME/ANSI Standard A 112 1917 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUF CTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER I declare that I hold an active California Slate Contractor license V -- Professional Engineer license# with Mics wimm or a California State 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[his information,i Shall be subject to potential disciplinary action at the discrelion of the licensing authority in accordance wit h California HeaIN&Safe CoOe Section 116064.2 Contraclor/ErigineerName- - / Company Name: - tv Company Address: City:� ' --`- Stale:_� _Zip Code: Contraclor/Engineer Phone Number; Call Phone Number Co lod6rgineer F (Number: /, 1k 1? �i or�Engover�meT_(PRINT) Contra v For a complete text of the law,visit http:((infosen.cagovipub/Og•10/biIV ngmeer rtarne(SIGNATURE) pale asm/ab 1001-1050/ab-1020 bill 20081011 chaptered.pdf 011 ARD