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APPROVED BY DATE: OFFICE USE ONLY GPM r g: GPM rating: Floor Well Skimmer equa size were found to be Installed on 0 Floor o Wall inches Number of Skimmers: O8/17/212 11:02 2095376599 CUSTOM POOLS PAGE 02/03 .alifornie 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 NOTE: Use one form for each Puma or mpltIpte Dumas under file unit troin ;over. 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 116014.1 and 1160841. Under Section 116084.2 (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 antl-entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and pirmits prior to construction or remodel. Site information Facility Name: 011 %Pe ilei.V K Pool Identification (if more than 1 pool/spa at site): S flit Facility Address: 146 rEogkh 5 ople.-- City; MAeti i(C,A- St CA -Zip: ?S3(.. Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 2010?: 0 Yes Pump information Recirculation Pump 0 Jet! Booster Pump Make/Model H.P Make/Model Other Pump: D Feature Pump Make/Model H.P Make/Model H,P H.P Main Drain (Includes All SUCtign 014tetSf-xcePt Bkimnler Eauelker Linea) Manufacturer of approved drain cover rhf-11- ekloutVf al) Model Number: -SCO4K-- Install date GPM rating: Floor abb Wall Installed on ,p-Fro-O-r 0 Wall Manufacturer of approved drain cover: Model Number: Install data GPM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is I/..) inches, Check One: Split mein 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) Single drain - tierunblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravityiltainage system, auto pump shutoff system, or other equally or more effective system approved by enforcement agency) Type of secondaty device installed: install data Manufacturer of approved device: ModaVPart umber: Safety vacuum release system bears the following performance standard markings: o ATSM F2387 SME/ANSI standard A 112.19,17 Skim Sr Equalizer Line(s1 Man acturer of approved suction fitting: HOJetivf Q PAC.- Model Nu is Ins 81,/Il LiE z 0 .. BEEN El e a A I N. Jo ' k ...... T - .. - i _LT • L : • IREMENTS lEtY THEIHSTALLER I declare that I hold an active California State Contractor license* with classification 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: Company Name: Aoki evslorm Pool] Company Address: ,.5-101C0 t."a postf., it, City: c. e State: C. i Zip Code: f`S-307 Contractor/Engineer Phone Number 5-31 --(0$-00 Cell Phone Number Contractor/Engineer FAX Number: Email; ,S4e4:4/4 ft1-4 4 ie_8117 eielpti.---- Contractor / Engineer name (PRINT) ctor / Engineer name (SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/b111/aem/ab_1001-1050/ab_1020_b111_20091011_chaptered.pdf Received Time Aug. 17. 2012 11:00AM No. 0893 Remiecr Jury 14, 2010