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APPROVED BY:
<br />DATE:
<br />FFICE USE ONLY
<br />ECE1 V
<br />Model Number; iL;{
<br />Installed on 0 Floor &Wall
<br />Skimmer equalizer line(s) pipe size were found to be inches Number of Skimmers:
<br />Skimmer Equalizer Line(s) r,
<br />Manufacturer of approved suction fitting: i—vg ,,,,A;
<br />GPM rating: GPM rating; Floor Wall 1-2
<br />California Department of Public Health
<br />Compliance Form
<br />Anti-Entrapment Devices and Systems
<br />for Public Pools and Spas
<br />Health and Safety Code Sections 116064.1 and 116064.2
<br />NOTE: Use one form for each pump or multiple pumps under the same drain CSAntficio,,," ,vivieNT ALL SECTIONS OF THIS FORM MUST BE COMPLETED. PERMIT /SF HEA
<br />qR
<br />A
<br /> ge This form Is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 1 aS _ _ and
<br />116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool
<br />shall file this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems in
<br />swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and
<br />permits prior to construction or remodel.
<br />Site Information
<br />'\' 1
<br />Facility Name: ki\j.-,•• ,-)',-,-,r1,7, c'---.2 't, \.-..,\ , .
<br />,:\ Pool Identification (if more than 1 pool/spa at s0): tA. )
<br />Facility Address: 19 ci, : Vki t-' \ ,r . 1 \ OIL._ city: sit \,/C,X,C: 7 sr-v, ..., . .. St .,( ii- zip: cFT, \ , Owner Name: \A„..i.c.,..i.,, cz2,..-.. )1V.) J4,Tys1 ..,, :-... Owner' Phone Number: •'.2.. .;-...5.5-) -Th•-••
<br />Owners Address ; cic i i,,-,.1 11,t i , t '1 % A,/ , , 1 7- ,- City ..t :Gk.:1y St / Zip(--E1:;•.-)' ILI--
<br />Pool constructed on or after January 1, 20107: E. Yes ' ' No /
<br />Puplp information
<br />ji Recirculation pum0,-) 0 Jet Booster Pump
<br />'Make/Model I H.P Make/Model H.P
<br />0 Other Pump: 0 Feature Pump
<br />Make/Model H.P Make/Model H.P
<br />Main Drain (Includes All Suction Outlets ,Except Skimmer Equalizer Lines)
<br />Manufacturer of approved drain cover -Ain \ F-:;-'-=‘,TC": k., Model Number: KI-:"› I .7.A...., i Install date )CN(' )
<br />GPM rating: Floor -77.1"tf---, Wall = Installed on Floor 0 Wall ,..... /
<br />Manufacturer of approved drain cover: M del Number: Install date
<br />'"? inches. Check
<br />rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is / _ Check One:
<br />; Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed)
<br />o Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment)
<br />0 Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent
<br />system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agency)
<br />Type of secondary device installed: Install date
<br />Manufacturer of approved device: Model/Part Number:
<br />Safety vacuum release system bears the following performance standard markings: 0 ATSM F2387 0 ASME/ANSI standard A 112.19.17
<br />Install date
<br />THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER
<br />I declare that I hold an active California State Contractor license # .74-1:1+00 with classification C-3•2.)144") or a California State ,. .
<br />Professional Engineer license # with qualified experience working on public swimming pools and that the information
<br />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
<br />disciplinary action at the discretion of the licensing authority in accordance with California Health 8 Safety4ocie„Sectiorl 116064.2.
<br />k j\‘ 14 i - i / I {,
<br />1 _. 1 .,..- \,' ..._.‘ \ , Contractor/Engineer Name:-.,..1c---,01.n. i 1 it Company Name: , _c.:,---...1./.: ;'' •, 6-1 .-,c.01 I.... (, , s. • ( ‘ / ,:, _
<br />Company otddress: ,...f.
<br />City: N.----‘ \if ' ./..- Vist.....-ier..) State: ( Zip Code: i A ,
<br />Contractor/Engineer Phone Number i ....7-7•—...! .„....: -r :41; 7 Cell Phone Number: ' '''' - '‘) 21'2' — ---/ '. .. 1=, ,- ,4,...,...../ - • ..
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<br />Cpritractgr / Engineer name (SIGNATURE) '' Dgte '
<br />For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/billiasm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf
<br />Contractor/Engineer FAX Numberi
<br />Contractor / Engineer name (PRINT)
<br />O NOT
<br /> scut414 2010
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