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Apr. 13. 2010 8:34AM an Joaquin county NO. Ub 10 r. APPROVED BY,: n Aifornia 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 OFFICE.USE ONLY DATE: 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 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 Blinding Department for any necessary plan approval and permits prior to construction or remodel. PUrn Information Recirculation Pugnp. . Make/Model f -hqya/-1R0 2 ,..) cici_xil p 7, 6 0 Jet 1 Booster Pump Make/Model H.P 0 Other Pump: 0 Feature Pump Make/Model H.P Make/Model H.P S C-:-) VA0 C ha ngineer name (SIG RE) Dale For a complete text of the law, visit: hltp://info_sen.ca.gov/pub 9-10 illiasmfab_1001-1050/ab_ 0_bill_20091011_chaptered.pdf Stale: Zip Code: Cell Phone Number .7 2 (2 3 33 c- c 4,f- FS Pool Identification (if more than 1 pool/spa at site)! ( City-. Str-X. kin") S Cz_t_ Zip: 7 2c2 7 Owners Phone Number: /44 city S172.-iL2+ct St. 64 Zip r7 207 Site Information Facility Name- ve 4I e Facility Address: / 5 'lc /L716 C ,41' Owner Name: F 6--) (/4., Owners 6 37 it/ 1/15 Owners Address Pool constructed on or af ler January 1, 20107: 0 Yes Main Drain (Includes All Suction Outlets Except Skimmer Equalizer Lines Manufacturer of approved drain cover ligis A AICP-N 4 Modal_Number: 5,0X Install date GPM rating: Floor 1)( rC., Wall /g 2_ Installed on Of 0 Wall Manufacturer of approved drain cover Model Number: Install dale GPM rating: Floor Wall Check One: Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is inches. 0 Sprit main drain(s) (Minimum 3 (t. between covers. hydraukcally balanced and symmetrically plumbed) 0 Single drain - Unbtoekable (size and shape that a human body cannot sufficiently block to create a suction entrapment) ,p-Single drain - Not unblockable (one of (he following secondary devices required: safety vacuum release system, suction limiting vent ' system, gravity drainage system, auto gup shyl-pff systm or other equally or mor effe tive stern approver) by enforcement agency) 'Type of secondary device installed: --- 11-A-%.) ii-c— ee "t -1.- Insley...gale (11 CAr/2_‘.9car- _ Manufacturer of approved device: A (..) ___ ,.--- c f 4.--e, - Model/Part Number 6--C4,4,r4, 01411-- Safety vacuum release system bears the following performance standard markings:0 ATSM F2387 0 ASMEJANSI standard A.112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION ROUlkEMENTS BY THE INS ALLER I declare that I hold an active California State Contractor license # S-750' //1 with classitIcation .2277,_.7 pr a California State C_T-- C / Professional Engineer license # ii..1 / 44 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 irnomperty certify this inforrnafion, 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. Contractor/Engineer Name: /VA k. ., -cketi, /4 1 / ,S,,,..L.4,-e-ri-, ..-) , ,--, Company Name: /...-67 f Company Address: C C.' 12tik _ /6', 2 4/ City: Contractor/Engineer Phone Number; .22C--ci 33 Contractor/Engineer FAX Number i C /-fk /17Irc 6- Contractor 1 Engineer n (PRINT)