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APPROVED BY: California Department of Public Health Compliance Form OFFICE USE ONLY Anti-Entrapment Devices and Systems for Public Pools and Spas DATE: Health and Safety Code Sections 116064.1 and 116064.2 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 118064.2. 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: Vera e-41 04,1 4 AP-V, 14045 , Pool Identification (if more than 1 pool/spa at site): 5 &a- pooi Facility Address: 15 3 I 10501c- t k City: 541204-#0A) St: CA. Zip: 9-C90 7 Owner Name: Owner's Phone Number: (7/77 ^ 79 7C0 Owners Address City St. Zip Pool constructed on or after January 1,2010?: 0 Yes /No ,ump information 0 Recirculation Pump a Jet! Booster Pump Make/Model H.P Make/Model 0 Other Pump: 0 Feature Pump Make/Model H.P Make/Model H.P H.P Aain Drain (Includes All Suction Outlets Except Skimmer Equalizer Lines) 367U)F1Pato/ Aanufacturer of approved drain cover: Aq:(104 •c1' Model Number: #1 Install date 40 Sia //3 3PM rating: Floor I la Wall Installed on /Floor o Wall Aanufacturer of approved drain cover: Model Number: Install date 3PM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is inches. ;heck One: o Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ,„Ierfingle drain - Unblockable (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 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 F2387 D ASME/ANSI standard A 112.19.17 Skimmer Equalizer Limits) Manufacturer of approved suction fitting: A CAM S-1-614 GPM rating: GPM rating: Floor Wall SI Skimmer equalizer line(s) pipe size were found to be I ti,t inches Model Number: Agaroi Install date 8 49 43 Installed on 0 Floor gi<Nall Number of Skimmers: cP 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 # to V/ 7 with classification C -5-3 or a California State Professional Engineer license # 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 116064.2. Company Name: C054-001 Pooki f Rernocialij Email: j 2-4 e-1 Cosildh g 4-.0 1 Coiln 14-010(111,1-4 81 /WO Revised: July 14, 2010 Contractor/Engineer Name: Company Address: t53 MQ542( 12.. City: Contractor/Engineer Phone Number: Contractor/Engineer FAX Number: poo 53 7 - ta-C99 ctor / Engineer name (SIGNATURE) Date For a complete text of the law, visit: http://Info.sen.ca.gov/pub/09-10/b111/asm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf sicPc44 mitc1,441-0 Contractor / Engineer name (PRINT) Cont State: C 4 _ Zip Code: 94-89/0 2 Cell Phone Number: 620 v s/Y54- 9 93-2