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13/08/2010 13: 59 Bertilacchi Insurance (FAX) 209 644 2521 P. 005/007 <br /> ------------ <br /> APPROVED BY: California Dep ment of Public Health <br /> I Compliance Form <br /> DATE: - <br /> Anti-Entrapment Devices and Systems <br /> -------------- <br /> for Public Pools and Spas <br /> Health and Safety Code <br /> Sections 1160641 and 116064.2 <br /> NOTE: Use one form for each pump or multiple pumps under the same drain cover. <br /> ALL SECTIONS OF THIS FORM MUST BE COMPLETED. <br /> This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections <br /> 116064.1 and 116064.2. Under Section 116064,2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of <br /> a public swimming pool shall file this form within 30 days following the completion of construction or installation of anti- <br /> entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building <br /> Department for any necessary plan approval and permits prior to construction or remodel. <br /> Site Informallo <br /> Faa-v),', <br /> c,d;�y Name Pool Iden ficanon <br /> , (f more than I booilspa <br /> at site). <br /> Facility Address: CAVrip City: q <br /> 4c, <br /> Owner Name. Owner's Phone Nu es ii <br /> Owners Adore -city „Zip <br /> Poc cristructed or,or after January 1. 2019? Y66 <br /> .............. <br /> P Information <br /> g <br /> (::Fke ulitl7nPumpJot I Booster Pump <br /> Maker'Model I I H.P Make/Model H P <br /> Other Pump:__ -j Feature Pump <br /> Make"Modei H P_ Make/Model —,----.H P­ <br /> Main Drain(Includes All Suction Outl2r Excq2t%mmgr 9gul II'Ler I-Ins) <br /> Manufactwer of approved drain cover: �1­, IZVodel NumbP� 2"'2Z I Z-CIrsitall date <br /> GPM rating. Floof--ZL2j.—wait H 2- Installed on 45<10or . Wall <br /> Manufacturer of approved drain cover Model Number ---Install date <br /> GPM rating Fioor­­-----WafI Installed on Floor Wall Marcs drain/.let suction Pipe size isinches <br /> Check One: <br /> Splhl main drain(s)(Minimum 3 ft. between covers hydraulically balanced and symmetrically plumbed) <br /> Single drain-Unblockable(size and Shape that a hillmari body cannot sufficienfly block to create a Suction entrapment) <br /> &r.gle drain-Not unblockable (one of the following secondary devices required safety vacuum release system,SLotiOrl lirriljng vent <br /> system. gravity drainage SYSIGM, auto PLIMp Shut-off System. or other equally or more effective System approved by enforcement agenc,"i <br /> Type of secondary device installed <br /> `011`108GIurer of approved device Model/Part Number <br /> Safety VICULIRI release system bears the following performance standar.i man,ings ATSM F2387 L AS'Ml standard A '11" 19 17 <br /> THE ABOVE HA§ BEEN FIELD VERIFIED TO 09M T!TUFACTIJREl INITALI ATION�EQUIREMENTS SY THE INSTALLER <br /> or f��L 3 a3&a California State <br /> i,, 4 <br /> declare that I hold ar.active California Slate Contractor <br /> Professional Engineer hcense# -with aoiified experience working on public swimming pools and that the information <br /> provided above is true tons best of my knowledge I understand that if i:rnproperly certify this information I shall be subject to potential <br /> disciplinary action at the discretion of the licensing authority in accordance with California Health&Safety Code Section I 1W64 12 <br /> 2 <br /> Contractor/Engineer Name �±A­1L-,L-�' L�rCompany Name <br /> Company Address EL11)—0 <br /> ty "4) ---.-- State.(_ _,_— Zip Code.( <br /> `0 <br /> Contractor/Engineer Phone Number4 t 7 <br /> D <br /> C,onlriNcrIngineer PAX m <br /> Nuber Fm/a,-, %0 "V, -A Y� <br /> i r41 g <br /> Contractor/ Engineer name (P� —(PRINT Contractor Engineer name lSiGNATURE%7 4sfA <br /> '-o <br /> a complete text of the law, visit. littp:l/lnfo.sen.ca.govipublOS-101bilitasmtab-1001.1050laO_1020_bl11_20091011_ohaptered,pdf <br /> ............ <br />