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APPROVED BY: :alifornia Dep ment of Public Health OFFICE USE ONLY Compliance Form DATE: Anti-Entrapment Devices an f1�n/j D for Public Pools and S UVJ Health and Safety Code JUL 2 0 2010 Sections 116064.1 and 111"A N IE��N��T11/H/ EALTH NOTE: Use one form for each Dump or multiple Dumas unde��tffd'Sifte�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--y ��5 Facility Name: — Pool Iden ' kation(if more than 1 pool/spa at site): I Facility Address: 3n1 �'1CYli-F62. C.I1?t'fP _�i^�r_,. City:[ Se�Zip: 521q Owner Name:�U_ S`1 r�r2_'Ny � i 4 C . . Owner's Phone Nu O Owners Address aJgZ? mt �}of i✓�IQA N a- City S t-Ky) St. Zip Qloa)q Pool constructed on or after January 1, 2010?: ❑ Yes C5�'No Pump Information Recirculation Pump,��, � � _ n Z ❑ Jet/Booster Pump Make/Model '�111�S.�A. li XAACfSI H.P Make/Model H.P ❑ Other Pump: ��J' ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outle Exce t Skimmer E ualiz r Lines) ��( Q 21 1 L Manufacturer of approved drain cover: odel Numbef*'rW`I `� Install date- I J! GPM rating: Floor ;?_('M Wall \Ci Z Installed on COWloor ❑ 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 '2 _ inches. Check One: "Z5-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 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 standard markings:o ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license#to C�j`SZ with classificati $r 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: Rob��- + 4. AkO - Company Name: k S Company Address: r(_) e_ City: 911-06A State: ' 1Zip Code: " ,S-3 (P Contractor/Engineer Phone Number. `i ( � Q Contr dor/Engineer FAX Number: Emai: J ' r�) Contractor/Engineer name(PRINT) Contractor/Engineer name(SI NA ate For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab 1001-1050/ab-1020-bill 20091011-chaptered.pdf