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.-bE0 or':Z 'unr \I ek\eAI c ')ciL(-VL "° —TOG 3 — p\,c,R4_4.1,,wss California Department of Public Health Compliance Form Anti-Entrapment Device!' and Systems for Public Pools and Spas Health end Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each gum, or 'math:4e Dump* under the same drain cover. ALL 8EC110N8 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 116084.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of • public swimming pool shall file this form within 90 days following the completion of construction or installation of antl-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. APPROVED BY: DATE: OFFICE tisis ONLY Site Inhumation, i Facility Name. Vers. e-4-‘a-IIN ?C1-0`' Ne-5 Pool identification (if more than 1 pooVspa at site); Facility Address: ‘5 40 Mc 506 C l.>340kAA City: ko-k-o fa St: CR Zip; 9 5 zo -I Owner Name; -1T-04- ''`- v121 Owner's Phone Number, ro b-1- - Crl 39 Owners Address City St. Zip Pool constructed on or after January 1, 20107: 0 Yes YNo tu_falt information j)1E Recirculatiorkrump ic . 1,_ Jet / Booster Pump Make/Model rfaafelk(a 1-XIDISell H.P \17- Make/Model 0 Other Pump: 0 Feature Pump Make/Model l-LP Make/Model H.P Main Drall flgcluileo All Suction ()until' Exceq§kirenaer equalizer Lines). Manufacturer of approved drain cover Ptit'S.CA-fir- Model Number: 3 2.CD 5.1;62 stall date GPM rating: Floor 3 lb ke.40,_ Wail 2,0$ oviv% I, isialled on i1floor 0 Wall Manufacturer of approved drfl cover Model Number. \ install date GPM rating: Floor Wall installed on o Floor 0 Well Main drain/Jet suction pipe size Is Inches. Check One: 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) jkSIngle drain - Unblockable (size and shape that a humeri body cannot sufficiently block to create a suction entrapment) o 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 vacuum release system bears the following performance standard markings: 0 ATSM F230T D ASME/ANSI standard A 112,19.17 10kImmer Enuelizer Limb!) Manufacturer of approved suction fitting: Altaok.,05(e Model Number Ag )0‘-‘0- install date GPM rating: GPM rating: Floor 100 .orp. Well 7 2' le installed on CI Floor PnWall Skimmer equalizer line(a) pipe size were found to be ./1-' inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WrIlIVANtiFACifURER'S INSTALLATION Rniji5.E14ENTS 13Y THE ITALLER I declare that I hold an active California State Contractor license ZiOez/F1-7 with olassIflcatione -5-3. or it California State Professional Engineer license # S1 t 7 " CA 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 & Safety Code Section 118064.2. Contra ctor/EngIneer Name:1)6`11‘ ‘RA *1C3VII\ Company Name: CZD11.0 C-05TOrn_ TI`SO Company Address: 5 2-vo Csivisi my,/ rci City: Contractor/Engineer Phone Numbere2-51 531 Of) 6 Cell Phone Number:0040 Los - Corttractor/Engineer FAX Number: SG( Email: Derw,/ "WP 6 - IS• Contractor7 Engineer name (PRINT) •ntractor / Enginb6r name (SI(3NAT RE) Date For a complete text of the law, visit: http://info.sen,ca.gov/pub/09-101bill/asm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf VO/D3 9Vc1 siood voisno 6699LES60 T:VT ZTOZ/8T/90 H.P State: Zip Code: et 530-7