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Owners Phone Number: 6,2- - CD-1'1cl City St. Zip cilA0 _ i790 '0 N 'Sl 'unr Nee.* OJt\xx-V- 154- (^)(".A1 -\•-yv,k0 te—A-Dr\_ California Department of Public Health Compliance Form Anti-Entrapment Device e and Systems for Public Poole and Spas LTHNealth and Safety Code Sections 116064.1 and 116064.2 PERMIT/SERVICES. fruit: Use one form for eaprt usornt or multiple atanoe_gnsier the eame drain scorn. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. Thla form Is to be treed 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 and-entrapment devious 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 Infenefloo ‘ Vex\ eA la" Afid-41"N3f Facility Name: 5 Facility Address: _15 L-ko Woci City: Sc) de-Aro st: C-Pc zip; Owner Name: 1-'710\C-1 SYlN e7 Owners Address Pool constructed on or after January 1,20107: co Yes rump Informelloo ,4 Recirculation Pump ,z.44 y Jet I Booater P Make/Model th)PiTST-0) RI -7 -C-510131:itta- H.P 'L' Make/Model 0 Other Pump: o Feature Pump Make/Model H.P Make/Model uxtttk I ?L0l5iNr-2.- H.P H.P main 12ralo Alt SucOon Outlet, Except Skimmer Equalizer Linea) Manufacturer of appwd drain cover AellIAA4Istr ,q 20-1;c1-(42- Xx4 Model Number: 37-CV fl-fe)°Install date GPM rating: Floor k Aos, Wall 2.6? Ar". installed on 0 Floor ADWall Manufacturer of approved drain cover Aiuck"*04-4)"" Model Number: \A5 ak Install date GPM rating: Floor l()t.) siffy- Wall ---)0 3 t installed on CI FlorierVall Mein drain/Jet suction pipe size is ) A-Inches, Cheok One: Spilt main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ci 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 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 veouum release system bears the following performance standard markings: ATSM F2307 0 ASME/ANSI standard A 112.19.17 Skimmer Equellzer LIne(s) UsE OFFICE QNLY Pool Identlficution (If more than 1 pool/spa et site): Model Number Installed on o Floor a Wall Inches Number of Skimmers: Manufacturer of approved suction fitting: GPM rating: GPM rating: Floor Wall Skimmer equalizer line(s) pipe size were found to be Install date THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURERS INE/kU_ATJON REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license with classification or California State Professional Engineer license It with qualified experience working on public swimming pools and that the Information provided above Is true to the beet 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 11E004,2, Contractor/Engineer Name-DaiNVAMCNNe-C- Company Name; Z Code: rT5-3 19 *7 Contractor/Engineer FAX Number: C7.041 5--0 '7\--)04\WA -Ve)ntker{— Contractor / Engineer neme (PRINT) For a complete text of the law, vlalt: http://Info.aen,ca.gov JR° VD Ng% k \N. EKc._ ''.-)e_i Company Address: 57-00 N\DA'S 11' e-r- irci City: 0-41/4/eg Coll Phone Number:(' Lk5 -C/C1 4)/ 7 i Contractor/Engineer Phone Number: (i.i' XI S3-7- 4Son State: Cl Contr or E blillas 6 - ems (SIC3NATURE) Date 001-105 020_b III _20091 011_chaptarad.pdf • 66992.ESS0Z ST:PT -00/81/90 siocid Hoisno PO/TO 39Vd