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APPROVED BY: 1. DATE: l.dl[t UT[tla IJepartment OT ruoilc tteann 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 Puma 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: b/ p Cc i 2407;' Pool Identicati t (if more than 1 pool/spa at site): Facility Address: /S// $/J ' ,D/L!`"� - / City. E e// St JfAZip: f'rj`" q !, Owner Name: Owner's Phone Number. Owners Address Pool constructed on or after January 1, 2010?: ❑ Yes ®'No 0 Pum rmation - Recirculation Py�mp /. , Jet / Booster Pump Make/Model „39 y—lrh/Da-t H.P Make/Model.P / ❑ Other Pump— ❑ Feature Pum Make/Model H.P Make/Model H.P Manufacturer of approved drain cover: GPM rating: Floor a=2 !� Wall Manufacturer of approved drain cover. _ rTi Model Number.. 5(h><- J?e 522= Install date /O Installed on - door ❑ Wall Model Number date urm rating: rioor wan Installed on D Floor ❑ Wall Main drain/Jet suction pipe size is inches. Check One plit main drain(s) (Minimum 3 It. 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 gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agency) secondary device installed: Install date cturer of approved device: Model/Pan Number. release system bears the following performance standard markings: O ATSM F2387 O ASME/ANSI standard A 112.19.17 hold an active California State Contractor license # _ with classification C 6 / or a California State Prof&ienaLEngineer license # with qualified experience working on public swimming pools and that the information prod` id--gbiWe is true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disci;"''K'Jction at the discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. c _. Cc racto ngineer Name: "wwl, iV' �vs�nr-Zv Company Name: r'x Company Address: 4i- L'r t/ 2l Gti ' City: 2'/ Lc y C, ✓ State: C14- zip Code: Contractor/Engineer Phone Number./ Cell Phone Number: Contractor/Engineer FAX Number: 9�;�.��;e Email: - Contractor / Engineer name (PRINT) Co r / Engineer name (SIGNATURE) ' Dale Fora complete text of the law, visit: http:irinfo.sen.ca_gov/pub/0-10/bill/asMab-1001-1050/ab-1020-bill-20091011-chaptered.pdf