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APPROVED BY: DATE: 00 90 California Department of Public Health Compliance Form Anti -Entrapment Devices and Systems for Public Pools and Spas .. Health and Safety Code Sections 116064.1 and 116064.2 OFFICE USE ONLY NOTE: Use one form for each pump or multiple pumps 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 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 Facility Name: _ Facility Address:. Owner Name: Owners Address Pool constructed on or after January 1, 2010?: Pool Identification (if more than 1 pool/spa at site): ��'�-. L -.City: �f or Li St Zip: �7 Yes ❑ No St.i6Zip Pump Information ❑ Recirculation Pump Jet / Booster Pump 1 Make/Model H.P Make/Model IoaA-QL H.P-2 El Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Manufacturer of approved drain cover: GPM rating: Floor 31 to Manufacturer of approved drain cover: sumr unes� Qnn"Model Number?�o2(2DV--LEPO[Install date (I !7 Installed onc:nFloor ❑ Wall Model Number: Install date GPM rating: Floor Wall Installed on o Floor ❑ Wall Main drain/Jet suction pipe size is e' inches. Check One: ❑ Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) mtSingle 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: ❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 I declare that I hold an active California State Contractor license # (p CJW l 2S L with classificati ifd` br 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 disciolinary action at the discretion of the licensina authoritv in accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Name: Isco -a -r f==- Q AU IsC,ft- Company Name: Company Address: faCo n F City: 1 6 A State: Contractor/Engineer Phone Number: `1) � q A-1 Cell Ph Contractor/Engineer FAX Number: QS-99 /?0/ Email: & contractor / Lngmeer name (F'KIN 1) contractor / tngmeer name (Sluw URL) uate 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.pof