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APPROVED BY: DATE: 11 tH. LI. LVIU IV: IY/ing J an Joaquin (Aunty No. 0652 P. 2 fifornia Department of Public Health - Compliance Fora' 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 116064.1 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 installatton 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 G.411,0 0,41/4/ "'ft 4144' Pool Identification (if more than 1 pool/spa at sit City: 7te:2‘.A Owner's Phone Number Owners Address Pu „mp-information w'RecirculatiourPumo,•_ Make/Model T/70.r/04/i) Vs"1/. • Hp CI Other Pump: Make/Model H,P Main Drain (Includes All Suction Outl s Except Skimmer Equalizer Lineal Manufacturer of approved drain cover. a 1.447‘ Model Number:524" /ern Install datef - t GPM rating: Floor Wall Installed on aKor D Wall Manufacturer of approved drain cover: (Zrayet-):4 Model Number;, VX ,rcif.:."› Install dale GPM rating: Floor Wall Check One; Installed on 0 Floor VfOg11- Main drain/Jet suction pipe size is inches. 0 Split main drain(s) (Minimum 3 (t. between covers, hydraulically balanced and symmetrically plumbed) la.,81h—gle drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 0 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: MOdef/Part Number: Safety vacuum release system bears the following performance standard markings:a ATSM F2387 0 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 ContraClor license tti• 5 5 /4,/ f"? with classification or a California State Professional Engineer license # with qualified experienceworking 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. Coniractor/Erigineer Name: Phi, // /VA/5 /,---; / / / // Company AddreS5f.egckf 2/2' City: 4.hiet i • /die Contractor/Engineer Phone Number: 209. -3...$)"71- k73'17/./2 Cell Phone Number: Contri. • • ' : ger FAX Nu er: ei it: 'ler For a complete text of the law, visit: http://info.sen.ca_gov/pub/09-10llksm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf 00 NOT DISCARD oFFICE.USE ONLY Facility Name: Facility Address: Owner Name; Pool constructed on or after January 1, 2010?: al Yes (Ooffo-' City St. Zip a Jet/ Booster Pump Make/Model H.P O Feature Pump Make/Model H.P Stale: G ____Zip Code: Con clor/ Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) For ?