COMPLIANCE INFO_PRE 2020 - Laserfiche WebLink

Home Browse Search

APPROVED BY: California Department of Public Health Compliance Form OFFICE USE ONLY Anti-Entrapment Devices and Systems DATE: for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE; Use one form for each Hump or muttiole pumos,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: APool tdentification(if more than 1 pool/spa at site); Facility Address: 0 City: &A St;�A__Zip; 4 � Owner Name: Owner's Phone Number: � yA Owners Address City St. Pool constructed on or after January 1,2010?; o Yes 1?No Zip Pu.%12.Inforr6ation Recirculation P p f �G ❑ Jet/Booster Pump Make/Model ► �P G H.P t Maka/Model O Other Pump: 0 Feature Pump Make/Model_ H.P Make/Model H p Main Drain Includes A11 Suction Outlet xce t Skimm r E ualizer Lines (' p Manufacturer of approved rain cover. Model Number; S `install date �� rY GPM rating: Floor_ 100 Wall Installed on �(Floor ❑ Wall Manufacturer of approved drain cover _ Model Number: _Install date _ GPM rating:Floor Wall Installed on ❑Floor D Wall Main drain/Jet suction pipe size is inches. Check One: fG Split main drain(s)(Minimum 3 ft. between covers,hydraulically balanced and symmetrically plumbed) ®4 Single drain—Unblockable(size and shape that a human body Cannot sufficiently pIOCk to create a suction entrapment) �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 Manufacturer of approved device: n t Model/Part Number: Sa*ty vacuum release system bears the following performs ce standard markings:O ATSM F2387 �r ASME/ANSI standard A 112 12.17 Skla tner E ualizer Lines i0anufpcturer of approved suction fitting; t I Model Number:_ i4 y 101 Install date 3 f 1 ry y GPM Eating:GPM rating:Floor Wall D Installed on ❑Floor kp Wall Skimpier equalizer line(s)pipe size were found to be riches Number of Skimmers; THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California T Contractor license# with classification or a California State Professional Engineer license# 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. , o > Contractor/Engineer Name: J�xrvj o aIf Company Name: Company Addr ss: fj City: �, Slate: L' Zip Code: Contractor/Engineer Phone Number: �' Cell Phone Number: f Contractor/Engineer FAX Number: Email: _ 0 Contractor/ ngineer n me INT} opt elor/ in e r name(SIGNATURE) {+ Dale For a complete text f the law,visit: http://info.sen.ca-gov/pub /bill/asm/ab_1001-1050/ab_1020_bill_20091p11_chaptered.pdf ftevs4q MY 14,2010 2,8:@6pd 82TOt7gb6081 :01 at7TUSS9Z6 0bZZZ9S9Z6:u6oJJ Z2:2Z iiaa-ze-nnf