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07-30-'11 16:21 FROM-Buckinham Property +559-452-8249 T-732 P0001/0001 F-464 APPROVED 6Y: 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 bump or multiple pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verity 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: Ak Pool Identification(if more than 1 pool/spa at site): Facility Address: f0.ft- fj�,„„,�f,-. ��,,,.� City..�S7aafn St:jCA-Zip: 9S.2iL0 Owner Name:/ Owner's Phone Number.X Owners Address X city X SL/Zip x Pool constructed on or after January 1,2010?: ❑ Yes No Pumn Information /`9/ eA—., G- Recirculation Pum O Jet/Booster Pump Make/ModeiX4� H.PZ5 Make/Model KP ❑ Other Pump: D Feature Pump Make/Model H.P Make/Model H.P Main Drain includes All Suction Outlets Except Skimmer E ualizer Lines) /^� Manufacturer of appronved drain cover: Model Number. Sl7.N. Install date_ ri 344" GPM rating: Floor 2.�2(Z Wall Installed on Floor O Wall �'��'7 Manufacturer of approved drain cover: Model Number: Install date GPM rating:Floor Wall Installed on o Floor O Wall Main drain/Jet suction pipe size is inches. Check One: ❑ 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) ))LSingie drain-Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system,auto purrm shut-off system,or other equally or more effective system approved by enforceme!it agency) Type of secondary device installed: � i.N.e_ Install date f 2 -/X D Manufacturer of approved device: n / Model/Part Number: SRAOO Safety vacuum release system bears the folloWri performance standard markings:O ATSM F2387 o ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: /Vr Model Number. Install date GPM rating,GPM ratingTFloor Wall"^= . Installed on 2-Floer---¢-W2l1 Skimmer equalizer line(s)pipe size were found to be . inches Number of Skimmers:-1— THE kimmers: / .— THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS 13Y THE INSTALLER I declare that I hold an active California State Contractor license# '7yx rr with classification a L-d/D•7Sor 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 i£Safety Code Section 1160642. ContractorlEngineer Name:�r �' Jrg e,_ Company Name: e .�mn,a.. �iV2 04 z 4.24 CompanyAddress: City: zsni gguz State: Zip Code: ' 7 Contractor/Engineer Phone Number ��y) •��-rCjz; Y Cell Phone Number. a_�) Contractor/Engineer FAX Number: E�sS�.) X92 2�� Email: G �4& - !/ Contractor/Engineer nam RINT) Cvr C#' or/Engi ame( NATURE) Date 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 00P, p !" "^ 411P ,. ; I )