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APPROVED BY: California Department of Public Health Compliance Form OFFICE USE ONLY 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 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 Building Department for any necessary plan approval and permits prior to construction or remodel. L A v\jr c>r '1C15) AC:..4001''ts)(2 , Owners Address lc?,I U. ,c e'" Pool constructed on or after January 1, 2010?: 0 Yes 7No Site Information Facility Name: Facility Address: Owner Name: Pool Identifirat on (if more than 1 pool/spa C 5t,siite): City: " • ) St.14- d( _Owne 's Phone Number: ?') <-47 Sti Zip City Pump Information ' Make/Model — p.u,mp e k H.P • •-• El Other Pump: Make/Model H.P o Jet / Booster Pump Make/Model H.P 0 Feature Pump Make/Model H.P Main Drain (Includes All Suction Outlets xcept Skimmer Equalizer Lines) Manufacturer of approved 000 cover: Model Number: V_t-7.- 1 Install date GPM rating: Floor Wall "'( :(,The !;,2 Installed on Floor 0 Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is 22./2 inches. Check One: .)94Plit main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) '0 Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) O Single drain - Not unbiockable (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: 0 ATSM F2387 0 ASME/ANSI standard A 112.19.17 )1 Install date Skimmer Equalizer Line(s) - Manufacturer of approved suction fitting: GPM rating: GPM rating: Floor Wall --) Wall Skimmer equalizer line(s) pipe size were found to be a_. inches Model Number: )t2XT Installed on/Floor 0 Wall Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY INITH MANUFACTURER'S INSTALLATION - EOURtytENTS BY THE INSTALLER I declare that I hold an active California State Contractor license # `--4-<)(-.:•,c with classificatiorCg i i i'i5or 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 autbority in accordance with California Health & afety Cogie,Sertion I 1604.2. , (— Contractor/Engineer Name: 1 , /A 1 \) n. 5 , - ) . Q' C ompany Name: CompelAddress 'I1-L A 1i'- City: L.,---A \.42 /?....VV,, A), . State: 1A-- Zip Code: — - -, 4 Contr For a complete text of the law, visit http://info.sen.ca.govipub/09-1 Thilliasm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf Contractor/Engineer Phone Number: CI 7C; '"' 63 V ContractoyEnginee Fl rber . 1 -.-- , K.',_,Y) 0\ i`• il, AVA. Contractor4/ Engineer name (PRINT) Cell Phone limber: Ema )27) tor /.ngineer name (SIGNATURE) • .te 00 NOT DISCARD Revised My 14. 2010 coo/milt suaw.idy atioasapasm I I0060 XVd gC:17-1 NON TI0UST/L0