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APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form Anti-Entrapment Devices and Systems DATE: for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE:Use one form for each dump or multiple Dumps 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 pian approval and permits prior to construction or remodel. Site Information "r Facility Name: !j Pool Identification(if more than 1 pool/spa at site): Facility Address: to City: 4.- Sr ;I-Zlp. Owner Name: Owner's Phone Number: Owners AddressftV St. Zip Pool constructed on or after January 1,2010?: o Yes o Purip4iliformation Recirculation Pump Jet/Booster Pump Make/Model H.P Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main in fIncludes All Suction Outlellr Manufacturer of approvedd 'n cover. Model Number:5� 6b Install date �'`�"7 GPM rating:Floor _ Wail Installed on o Floor ❑ Wall Manufacturer of approv d gr in cover: Model Number: t .- Install date T � GPM rating:Floor a Wail Installed on ❑Floor ❑Wall Main drain/Jet suction pipe size Is inches. Check An Split main drains)(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:❑ ATSM F2387 ❑ ASME/ANSI standard A 112,19.17 Skimmer Eauafizer Line(s) Manufacturer of approved suction fitting: Model Number: Install date GPM rating:GPM rating:Floor Wall _ Installed on ❑Floor ❑ Wall Skimmer equalizer line(s)pipe size were found to be Inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY ITHMANUF TURERIS INSTALLATION RESUIBEMENTSE INSTALLEg I declare that I hold an active California State Contractor license#_7to 7 1 Z4 with classification -J 3 or 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: t t i&_ W_6 o o e IiL Company Company Address: OA-t4" P— mu/ City: !st !_, State: Zip Code: A( Contractor/Engineer Phone Number. t C(Q — Cell Phone Number: Contractor/Engineer FAX Number. cl l to_ ` Zd�cD ail: 16214 e t M(KeaAe> Contractor/Engineer name(PRINT) Cophtreldictor Engineer name IGNATURE) ate For a complete text of the law,visit: hftp!l/info.son-ca-gov/pub/0%10/blil/asm/ab..-1001-105UYab1020 bill_20091011 cheptered.pdf Revised:July 14,2010