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APPROVED BY. California Department of Public Health Compliance Form OFFICE t.isE 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 puma 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 115064.2 (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. Site Information Facility Name: 2 Pool identification (if more than 1 pool/spa at site); Facility Acldress: City: /1.1- St: eit Zip: 95-N Owner Name: Owner's Phone Number: 1-0 3 9 ,p7 3 76 St. Zip Owners Address Pool constructed on or after January 1. 2010?: City 0 Yes liNo Pt5,? r, Information Recirculation:fit: Make/Model ID Other Pump: Make/Model H.P H P H P 0 Jet! Booster Pump H.PA t 0 Make/Model 0 Feature Pump Make/Model Main Drain Includes All Suction Outlet xce t Skimm r Equalizer Lines1 Manufacturer of approvedArain cover. CLat !Irk 11 dig. Model Number: GPM rating: Floor 0100 Wall Manufacturer of approved drain cove If° Installed on loor o Wall ki(g r: Model Number: \ Install date GPM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe Size is Check One: 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) IlIC=110 0 Single drain — Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 4c=ok Single drain — Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent System, gravity drainage system, auto pump shutoff system, or other equally or more effective system approved by enfor ement gency) Type of secondary device installed: Install date iA Model/Part Number: fe,....6240 Manufacturer of approved device: ty vacuum release system bears the following performa ce standard markings: 0 ATSM F2387 ASME/ANSI standard A 112 19.17 er Equalizer Line(g Manufacturer of approved suction fitting: Cell Phone Number: Email: Ruvcsul July 14, 2010 Sti,k Install date a a yi inches Contractor/Engineer Phone Number: Contractor/Engineer FAX Number: q I. Contractor/ ngineer n me INT) '. :tor/ ne r name (SIGNATURE) Date Fora complete text. f the law, visit: http://info.sen.ca.gov/pub 5. IJbill/asm/ab_1001-1050/ab1020_bill_20091011_chaptered.pdf Contractor/Engineer Name' (-1-4— Company Name: Company AddAss: City: c ame Model Number: 184V 1,01 Installed on 0 Floor .,111Wall Number of Skimmers: I THE ABOVE HAS BEEN FIELD VERIF ED TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE NSTALLER I declare that I hold an active CaliforniUke Contractor license # Professional Engineer license # with classification or a California State with qualified ex erience 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 authority in accordance with California Health & Safety Code Section 116064.2. si . GPM rating. GPM rating: Floor Skimmer equalizer line(s) pipe size were found to be 14 < inches Slate: Zip Code: Install date 2/2:a6ed 82-MI797602T:01 ORTTL9S9T6 ObTTL9S9T6:w0Jd T2:2T TT02-/0-112