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APPROVED BY: RiCEIVED AUiferiiiiiiMilartment of Public Health Compliance Form ENVIRONteiNITAlfalikraia*Ivices and Systems PERMIT/SEVKlifk 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 Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information Facility Name: Vewa-1-1 cu4 Apis Pool Identification (if more than 1 pool/spa at site): 13".(-Y. N o( Facility Address: 153 ("\O$- DR City: ,S-i-ock4+o(%1 St: C.A.Zip. Owner Name: Owner's Phone Number: iet Owners Address City St. Zip Pool constructed on or after January 1, 2010? Li Yes vlJo Pump Information CI Recirculation Pump El Jet / Booster Pump Make/Model H.P Make/Model H.P 0 Other Pump: 0 Feature Pump Make/Model H.P Make/Model H.P Main Drain (Includes All Suction Outlets Except Skimmer Equalizer Lines) Manufacturer of approved drain cover: A Oth, .5±a A. Model Number: &Pc OFLFR/o/ Install date 7 // /42 GPM rating: Floor 316 Wall 49o8 Installed on Wrrloor ri Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on ii Floor E Wall Main drain/Jet suction pipe size is inches. Check One: CI Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) /*Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) , D 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 syster9, or pther equally or more effective system approved by enforcement agency) Type of secondary device installed: V. .5 12. I es 12es Install date Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings: El ATSM F2387 CI ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: A g;1/4-// 4-S1-aK Model Number: A 814..1 0 I Install date 74 /1.3 GPM rating: GPM rating: Floor i V5- Wall BY Installed on Li Floor ZWall Skimmer equalizer line(s) pipe size were found to be 1 /i& inches Number of Skimmers: (2 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 # 81 08`, 7 with classification C-53 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. Contractor/Engineer Name: Company Name:•('- °!_.;./I.`i ,, ifIG't.S. ';',:.Mesieliy Company Address: ''::::24.1' ,,% leah:$11,9c.Z. City: Ce_1/4:c.s State: C - 'J. Zip Code: 9 3c) Contractor/Engineer Phone Number: Cell Phone Number: /0",); fr - 2 -,) 3- (-.3--1 Con ctor / Engineer name (SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf Contractor/Engineer FAX Number: ,AAkt-ti t-4(.0 Contractor / Engineer name (PRINT) Email: geo/ec,:...thim 6.__19-4, it044,4,6 S Revised: July 14, 2010