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Apr, a zUlt) 10:19AM an Joaquin County No. 652 P. 2 • , APPROVED BY: I DATE: • lifornia 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 pump or multiple pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. OFFICE USE ONLY 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 Budding Department for any necessary plan approval and permits prior to construction or remodel. Site Informatto- Pool Identification (if more than 1 pool/spa at site): city: -S;`i,/ St(// Zi p ? — Owner's Phone Number_ Owners Address City St, Zip Pool constructed on or after January 1, 2010?: 0 Yes KNO Pumsinfomiali on .0--Recirculatio ump Make/Model 1:1 Other Pump: Model Number: //2/§c Installed on D Floor gg-477311 Main drain/Jet suction pipe size leizdeais2/Y4.3 .4 1/f69 inches. Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings: o ATSM F2387 C ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license tr5-3 ecf76757 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 ill 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. Contractor/Erigineer Name: Of 4/41 /(1C Contractor/Engineer Phone Number. _9e!9/ -23‘-/-7 ? _3 Contractor / Engineer name (PRINT) 00 tor / Engineer name (SIGNATURE) Dale 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_cheptered.pdf OONEICARO Facility Name, (//7 64/ 477. _ aird_eaS Facility Addressiztn-5- /1/k..440,4 tyl Owner Name: o Jet/ Booster Pump Make/Model HP Manufacturer of approved GPM rating: Floor Check One; Manufacturer Of approved GPM rating: FlOOr .1/4 0 Feature Pump Make/Model H P Main Drain Includes Alf Suction Outle s Exce Skimmer E ualizer Lines Make/Model drain cover 1,-/A Model Number ..3,219i--L Install date /0 -//-72 Wall ';‘) Installed on 49-P1oor 0 Wall drain cover: Wall y6 H,P ZI Split main drain(s) (Minimum 3 It. between covers, hydraulically balanced and symmetrically plumbed) drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) iJ 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, Of other equally or more effective system approved by enforcement agency Type of secondary device installed: Install date Company Acid74)./Y/T City: Stale: Zi.(f Zip Code: Cell Phone Number: Conlractor/Engineer FAX Number: