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„.,. .. r. cuiv I.J. renin APPROVED BY: DATE: adn Joaquin bounty No. 0652 P. 2 :alifornia Department of Public Heal,.. OFFICEMSEONLY Compliance Form 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 Lumps 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 is a public swimming pool shalt file this form within 30 days following the completion of construction or installation of anfi- 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. Facility Name: s/g/` Facility Address �C � j� Owner Name: Owners Address Pool constructed on or after Pumformation Pool 1, 2010?: ❑ Yes &W O Reclrculalio Make/Modei�/,"yip//' ❑ Other Pump: Make/Model u o ('If more than 1 pooUspa at Owner's Phone Number. ❑ Jet/ Booster Pump Make/Model o Feature Pump Make/Model Manufacturer of app ved drain Cover /1 Motlel mberall ��i GPM rating: Floor - V' %'� Wal Install date ManufacWrar of a Installed on nor ❑Wall approved dein cover. Model Number, CPM rating; Floor Wall Install dale Check One: Installed on o Floor m.YNall Main drain/Jet suction pipe size t5 ” r inches, O Split main drain(s) (Minimum 3 It between covers. hydraulically balanced and symmetrically plumbed) SiLO drain — Unbiockable (size and Shape that a human body Cannot sufficiently block to create a suction entrapment) orain — Not unblorkable (one of the following secondary devices required: safely vacuum release system, suction limiting vent syslem, gravity drainage system, auto purq ul- ff sy�lerr)r'��p)tI Type of secondary device installed- /L ��/ 2- L' er equally oar. 10�r e sy lem approved by ento .ce ent a icy) Manufacturer of approved device: _ .r (� Install data G " Safety vacuum release syslem bears the folfol. Model/Part Number: g Performance standard marWngs: o ATSM F2367 0 ASME/ANSI standard A 11219.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFARR's INSTALLATION RE UIREM =NT BY THE INSTALLER I declare that I hold an active California State ConnClOr license # Professional Engineer license # with qualified expedence workin onPublicssw�nun n S� or a California Slate Provided above is true to the best of my knowledge. I understand that if I im ro9 g Pools and that the information disciplinary action at the discrelion of the licensing authority in accortlance ith C811 mia Hearlth 8 Safety Code Section subjects information, I 0all be 16064.2 tential Convaclor/Edgineer Name Company Address: *11 City: ro Contractor/Engineer Phone Uonlr2clor/ Engineer name For a complete text of the law, visit Company Name: Stale: G 17— Zip Code: _ Cell Phone Number: 20091011_chaptered.pdf RD