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OFFICE US E ONLY California Department of Public Health Compliance Form 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 #ach 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 1160641 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_ Site Information Facility Name: Facility Address: Owner Name: Owners Address City Pool constructed on or after January 1, 2010?: Q Yes No APPROVED SY: CATE: Pool Identification if more than 1 City: _1114_ spa at site): Zip: Owners Phone Number; St. Zip _ Pump Information X Recirculation P mp Make/Model LI Other Pump: Feature Pump Make/Model H.P Main Drain Includes All Suction Outlet t Skimmer E ualizer Lines) in Manufacturer of approved dra cover als405,441b14 _ Model Number: Install dale GPM rating: Floor 2.4).e _ Wall I 40-2- Installed on kftloor 0 Wall ManufaCturer of approved drain cover Model Number: GPM rating: Floor Wall _ __Instafidate Check One: Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is inches. 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) i 0 Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system. suCtion 'milting vent system, gravity drainage system, auto pump s Make/Model 1-1,P XCe 0 Jet / Booster Pump Make/Model H P U -0 syStere, Of other ype of Secondary device Installed: equally Of more effective system approved by enforcement agency) Install date - 7,- Manufacturer of approved device: -I Model/Part Number Safety vacuum release system bears the following performance standard markings:0 ATSM F2387A,A-SME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license # with classification ( 3 _or a California State Professional Engineer license #_61ft- 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 authority in accordance with California Health 8. Safety Code Section 11 0642. Contractor/Engineer Name: ---._%-e Company Address! 34_.01 :0 Company Name -klaft-R City: __P__h 0 70 i) t _ stale: A.=, Zip Code: r_c: 0 Contractor/Engineer Phone Nurnbe—r: K.4,-"W„.77 Cell Phone Number 9111-- _c4q Contractor/Engineer F Number 9/111__!_i_ta:_ti. Contra or / Engineer name (PRINT) ctor E gin Cr name (SIGNATURE) Fr a complete text of the law, visit: http://info.sen,ca.govIpub/ /billiasm/ab_1001.10501ab_1020_b111_20091011_chaptperaeted.pdf 0i2TTL9S9TE:w 0 JA 2T:t7T OT02-82-Nnf 82-MI7917602T:01 017TIL9S9T6 2,2:a6ed