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07-30-'11 16;21 FROM-Buckinham Property 559-452-8249 T-732 P0001/0001 F-464 APPROVED BY' 1;1 Californias a Departm nt of Public Health OFFICE USE ONLY �t ✓Compliance Form IFI An -entrapment Devices and Systems DATE: I for Public Pools and Spas O at and S f ty Code Sections 116064.1 and 116064.2 NOTE:Use one orm f ch um or multiple pumps under the same drain cover- ALL SECTION 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 pool& 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: M_mz�6a � are, .40r Am fnlr Pool Identification(if more than 1 pool/spa at site): Facility Address: lr"c City. _<)�>afn St: zip: 9S 2 fL— Owner Name:X Owner's Phone Number. X Owners Address X_ City A' S1.4Zip X Pool constructed on or after January 1,2010?: ❑ Yes X No Pump Information r7(/Ti�i� OC � R- rculationPump O Jet/Booster Pump Make/ModeiX��ig[/Gr]iFiP/J 10 H.P z Make/Madel H.P O Other Pump: Make/Model Pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outlets Except Skimmer E ualizer Lines r Manufacturer of appmrvled drain COV2C Model Number: �L77yt Install date h�34 ' GPM rating:Floor 2.(, Wall Installed on ) Floor O Wall �'�'�'7 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 inches. Check One: O Split main drain(s)(Minimum 3 ft.between covers, hydraulically balanced and symmetrically plumbed) O 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 pu sh toff system,or other equally or more effective system approved by enforcement agency) Type of secondary device installed: .,� .e_ Install date,/.? Manufacturer of approved device: 5%;4/tModel/Part Number: Safety vacuum release system bears the follgwin performance standard markings:O ATSM F2387 o ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(a) ,/� Manufacturer of approved suction fitting; /V.r r� Model Number. �- Install date GPM rating:GPM rating^Floor Wal1"^�= - Installed on 0_-Floar�-Wall Skimmer equalizer lina(s)pipe size were found to be . Inches Number of Skimmers: 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# 9JYZ f(' with classificationkL-L� - ora 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 Narne: .e ��. Company Name: Company Address: g1_I/ 'r �.y7_ti✓ City; /S-e cyfa �„State: �� Zip Code: Contractor/Engineer Phone Number: - Cell Phone Number.14l2 /-" �5- s Contractor/Engiinser FAX Number: 5) ,L92,�� Email: / Contractor/Engineer nam RINT) Cvr fra or/@ngl ame(SIGNATURE) Date For a complete text of the law,visit: http://info.sen.ca.govipub/D9-10/billiasmfab_1001-1050/ab-102D bill-20091011_chaptBrad-pdf �iii�w �. r^ r^ ' �''-"' �' a i ,