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APPROVED BY: t.dtlturnia uepartmerlt of 1-11D11C rleann OFFICE USE ONLY Compliance Form DATE: Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each Dump 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: G Pool IdentlFpti n (tf mor than 1 pool/spa at site): Facility Address: /S// C�� n� i/r' City. St: r4Zip Owner Name: _ Owners Address Pool constructed on or after January 1, 2010?: ❑ Yes Owner's Phone Number. rum rormacwn ecirculation Pump, / eJet / Booster Pump �� / 1 Make/Model Ff-B-�/L�pry 10( H.P,�_ Make/Model �j21k-,��- �yy di -y 5Xe2 H.P? .-L O Other Pump: ✓ O Feature Purfip Make/Model H.P Make/Model N o Manufacturer of approved drain cover. GPM rating: Floor 62�2C=)V Manufacturer of approved drain cover. Model Number: 2p A Install date Installed on -. Floor O Wall Model Number. 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) OSiOgle drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) Ingle 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:' S'd i%s Install dale a Manufacturer of approved device: 6:: Model/Part Number. 22 -cST- Safety vacuum release system bears the following performance standard markings: ❑ ATSM F2387 O ASME/ANSI standard A 112.19.17 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 # %/3o?74,�,e with classification r- 6/ 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 8 Safety Code Section 116064.2. Contraclor/Engineer Name:�%'J9 tOfi via 4; 11 Company Name: LX��C Company Address: //_A c'—/ _ City: Ole tic State: (f4- Zip Code: /ice .;2 -,-:;? Contractor/Engineer Phone Number. J"%� �/�1-✓//>� Cell Phone Number. a /3 %ii,�� Contractor/Engineer FAX Number: /dt�//,y,Zp Email'�C/fI�>fs� o �`%�6' ��' �L (r_A 2E7�,eC/SSG+ Contractor / Engineer name (PRINT) ontractor /Engineer name (SIGNATURE) Date Fora complete text of the law, visit: http:/Ftnfo.sen_ca.gov/pub/09-10/bill/asagab 1001-1050/ab-1020—bill 20091011_chaptered.pdf unu�iQ1�CP�u