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AD!". 13. 2010 8:34AM San Joaquin County Ito.Ub lb r. ,lifornia 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 APPROVED EIY,; DATE: OFFICE.uSE ONLY NOTE: Use one form for each 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 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 poof 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: V6-4,1 e_ t ( (4 -, Pa-/2 lc 7F5 . Pool Identification (if more than 1 pool/spa at sire)1,-; y Cit SICr- tt-ri -C-Q-- e-1 Facility Address: /5'/C / E-/O SA; c c.....44y, sir4 Zip: ce7-S-2-0 7 Owner Name: F ) 6,._Je f / e eAlift,.S fej?„-p..,.47. Owners Phone Number: Owners Address .56::: 37 it( t4,----3/t iit_5 /4- i.fr city Stva_i...2-i-(:= , si. (-..". 4 Zip (7 S-2c7 Pool constructed on or after January 1, 2010?: 0 Yes ,,..131No Pump information 0 Recirculation Pump 13/ump Make/Model HP Make/Model U..4474e11--2-4/4( 0 Other Pump: 0 Feature Pump MakelModel H.P Make/Model Main Drain (Includes All Suction Outlets ,,)cept Skimmer Equalizer Lines1 Manufacturer of approve drain cover / ,---i ,/,4 74 /4, 2. Yype at secondary device installed: X Z " equally Or more e active system approved by enforcement agency) c e ti-ree-1.-e" Manufacturer of approved device: ( Install le (1'l 012 ,ack--- Model/Part Number r-L4-c.4e Cy Safety vacuum release system bears the following performance standard markings:0 ATSM F2367 a ASME/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; 'C4-750 //I •e with classification /)or a California SlateCr- 4: / ProfeSSiOnal Engineer license # i'ci / A with qualifier, experience working on public swimming pools and that the information provided above is true to the best of my knowledge. I understand that ill impropedy certify this information, I shall be subject lo potential disciplinary action at the discretion of the licensing authority in accordanr,e with California Health & Safely Code Section 11 6064.2. "Cketi e City: e__CyCkt- -i__ Stale: (2,..4. Zip Code: 9 ---s-2— '7-1 Contractor/Engineer Phone Number; 2i-Cf ei 33 5' - ct-7.2 Cell 13 _s RE) 'et )/rHP n _53— H.P ( c-- ' Wan 7C.) Model Number: ?AU ('e-) I Install dale C/-2. GPM rating- Floor SfiC Installed on,.0--Mor 0 Wall Manufacturer of approved Crain cover Model Number: Install dale Check one: GPM raring: Floor Wall Installed on 0 Roar 0 Wall Main drain/Jet sOCilOri pipe size is inches. o Split main drain(s) (minimum 3 it. between covers, hydraulically balanced and symmetrically plumbed) 0 Single drain - tinblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) .,....0-Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto p shut-,off, syste . Company Address: C.) 6(1 ' ContractodErigineer Name: /11/1 1 Company Name: 4 // / ,-7 , S ; ne Number .;2 Cr Contractor/Engineer FAX Number: 720" ci 33 cis 9 2 "--7" #cli- • ContraCtorl Engineer n e (PRINT) Cerra or! Engineer na SIG For a complete text of the taw, visit; http://info.sen.ca.gov/pub/ -10/hilllasmfab_1001-1050/8 3 7s 7 7 ce-)ky Date 1020_bill_20091011_chaptered.pdf