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APPROVED BY:
<br />DATE:
<br />44,
<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 cover,
<br />ALL SECTIONS OF THIS FORM MUST BE COMPLETED.
<br />This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 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 />\I 1 ( Facility Name \g'\..) r 34;17 '(-r:-.) f c "r'''' A Pool ldenti on (if more than 1 pool/spa pite):
<br />Facility Address: \ 1 ,-,1 kJ\ ,,,1 ( q —: "1 ,'-', i I" City: A a St( .L{ Zip:
<br />' 't ' I 'N
<br />„. , , - / • -
<br />Owner Name: \ /J. f ,, ,Itc„..r>c--71i-62 -14.› i _Owneis Phone Number: :
<br />Owners Address -rc:--1:q u1/2....\.. ils,a . A,:, )
<br />•...._
<br />city c7c-xey Sti/). Zip
<br />Pool constructed on or after January 1, 2010?: 0 Yes No
<br />OFFICE USE ONLY
<br />I
<br />Pump Information
<br />0 Recirculation Pump
<br />Make/Model
<br />^ /%/0.,. _Jet BoosterZ!-ump
<br />H.P Nake/Model I bek.zb•-•
<br />
<br />O Other Pump: 0 Feature Pump Make/Model H.P Make/Model H.P
<br />44k)
<br />Main Drain (Includes All Suction OutletstExcept Skimmer Equalizer Lines)
<br />Manufacturer of approved 5.cayi cover: J--itr. Z2k -,- c..., Model Number 'iL.)---7.: /1' ' ' 2.1 ot. install date (
<br />GPM rating: Floor 21' :1"—. / Wall Installed on KFloor 0 Wall -r.... -...,---
<br />Manufacturer of approved drain cover: Model Number: Install date
<br />GPM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is . —2-> inches. Check One:
<br />IN, Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) 7 N.
<br />0 Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment)
<br />7.1 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 />Skimmer Equalizer Line(s)
<br />Manufacturer of approved suction fitting: ,. ' e--4•\--,-,„--• Model Number: C3(4-SCDC:::)\ Install date ,'ILI: )c- ili: . 4 t-... 7.,t,-..9
<br />i...- GPM rating: GPM rating: Floor (.'
<br />-, 4 1 tc, Wall Installed on,,kFloor 0 Wall
<br />Skimmer equalizer line(s) pipe size were found to be 2— inches Number of Skimmers: 2_
<br />THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQ REMENTS BY THE INSTALLER
<br />I declare that I hold an active California State Contractor license # 744-;45 `1‘4, with classificatior(S-3, 1;6••';'--)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 & §afety Cogle,,Sgctign 116064.2.
<br />Contractor/Engineer Name '(• -e - A • - ' i, Company Name 1-4:.,?...2,\, :••I.'$ A.t..'i''',` :1..ifs, I-''. ,-A, Y ..•_.- . , , „..i. 1 — /- Company Address: 1-.).›S: .--r- t..A.,:r"...i kLf'. - . '.--.1:::.'''[LeVi.,...) fi-VAA, 1
<br />) City: .-4‘,..,ri'-' :,",'`...b"V' A; .-.7 State: , ---Zip Code: . ... ..- ,-•---, --7 A:\,.-- Contractor/Engineer Phone Number 61 2 \--,---4--;......( -- ,...5 --) -t-... Cell Phone N/imber: ‘-`4"'''" ;'5 7 -z , • •• e
<br />Contractor/Enginee‘FAX ftgmber: L" - ,- ),...._- . ..; . - '.7(.77 -2--. Erna' : . .kk-A- k\ta.(1,2 It:Zy, (jr. L---r-94. --- -.' `-‘--)?'
<br />. .
<br />. , :1-
<br />••-•:. \ It:,, . - -..... .,. „, ,.. k. • , •
<br />12,71 / /I II / i
<br />.g /
<br />1". ' 'Ce i 1 , 1 1 •:. 1
<br />Date
<br />
<br />Contractort/ Engineer name (PRINT) Contr tOr /Engineer name (SIGNATURE)
<br />For a complete text of the law, visit: http://info.sen.ca.govipub/09-16./billiasmiab_1001-1060/ab_1020_bill_20091011 chaptered.pdf
<br />00NOTOISCARO
<br />
<br />Revised. July 14. 2010
<br />sluowldudy off61-§do1W-TR9TOR960Z Y'siA 9tt'T NON TT0Z/9T/L0
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