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Company Name: "trzi f p 1.5_'11/ i 2 _2 4/4 a--I2-3d 2 State: Zip Code: Cell Phone Phone Number; Contractor/Engineer Name: Contractor/Engineer Phone Number; Contractor/Engineer FAX Number: Company Addr City: Wee' NOV. 5.2010 9:21AM DER NO. 6184 fl Ilf f • i f uompliance orm „ DATE: Anti-Entrapment Devices and Systems for Public Pools ahd Spas 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 116084.2. 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: Pool Identification (if more than 1 pool/spa at site): Facility Address: City: 5/ /-'i'7 Ste', I Zip: Owner Name: Pu • information Recirculation,f-ump g 7.7 0 Jet / Booster Pump Make/Model pite 4±/62 H.P /5 ' Make/Model H.P 0 Feature Pump Make/Model H.P Make/Model H.P Main Drain (Includes All Suction Outlets Exce)t Skimper 94ualizer Lines) ---2 -) ' Manufacturer of approved drain cover: _7::., &//7ç/ 6,-/,;,;? Model umber. ...),( c---Kff Z-1 Install date .) GPM rating: Floor _3Ce 't Wall Installed on oar 0 Wall Manufacturer of approved drain cover; Model Number: . Install dale, ., GPM rating: Floor Wall Installed on 0 Floor 0 Wall 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) wrliTIgle 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, autcurnp sh4-0/system, or other equally or more effective system approved by enforcement agency) Type of secondary device Installed: 1 i,1‘2 0 1 A z'/) Install date Manufacturer of approved device: Model/Part Number; • Safety vacuum release system bears the following performance standard markings: u ATSM F2387 0 ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: yiw..,1/4 /1-- . Model Number //9 4 1/AP) Install date ,-L GPM rating: GPM rating: Floor Wall /if(' Installed on 0 Floor Cr1A--/—a-11 Skimmer equalizer line(s) pipe size were found to be inches 01) Number of Skimmers: .2? • THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S iNsTALLAT1ON REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license # 'Y/' /7_7 j with classification,• ' 5-71 or a California State Professional Engineer license # with gualttled 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. Owner's Phone NurTher Owners Address City St. Zip Pool constructed on or after January 1, 2010?: 0 Yes 0 Other Pump: _ Contractor I Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) For a complete text of the law, vlsit: httpl/Info.sen.ca.gov/pub/09-10/bill/asm/ab_.1001-1050/ab 1020 bill 20091011_chaptDeraeted.pdf _ _ FlEPARKI. July 14, 2010