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• APPROVED BY: 'ifornia Department of Public HealtF 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 pump 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 poor 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: W�W5e- Q31l Pool Identification(if more than 1 pool/spa at site): 1 Facility Address: _36— iY�,�ieh/ City:_�- St: C*4 Zip: Owner Name:"lo ko-r., Owner's Phone Number� =�� Owners Address 3'-d oC City 154*111 St. Zip 4 C-Z_0 1 Pool constructed on or after January 1,2010?: ❑ Yes PuEiulp Information Recirculatio Pum ❑ Jet/Booster Pump Make/Model ,r —H.P 3A Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain(Includes All Suction Outlets Except Skimmer Equalizer Lines) Manufacturer of approved drain cover: Model NumberUASS 1L XW Install date GPM rating: Floor 36 Wall[[� � Installed on Affloor ❑ Wall Manufacturer of approved drain cover:-44' Model Number: Qo rA U&m-eWstall date G'/-ZO!(� GPM rating: Floor 3g Wall 3G/ Installed on iWoor ❑Wall Main d in/Jet suction pipe size is_1�inches. Check One:- Rt.�v V V1il.r� w�" b� t� �� MG+,� Dry, split main drain(s)(Mii rm 3 ft. covers,hy4Feekea4r43;a(anoe+9md bed), ❑ 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 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# 14 ( with classification D'3S L" dM 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:� Se:5 C,cJ Company Name: &g6&ul_ Q� ASO h Company Address: _.ItL W ft-, 1J City: ,mow State:GA Zip Code: r1 sZG� Contractor/Engineer Phone Number:1W41 l`�- �( —Cell Phone Number: Contractor/Engineer FAX Number: Email: Contractor/Engineer name(PRI ) Contractor/Engineer name(SIG ATU 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