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APPROVED BY: DATE: ...alifornia Department of Public Hoak,. Compliance Forth • Anti-Entrapment Devices and Systems for Public Pools and 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. oFFICE.USE ONLY Apt. //. lull) 10:19AM San Joaquin County No. 0652 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 shalt file this form within 30 days following the completion of construction Or installatton 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 n Facility Name: .i(jC.'/ti rsrv.J Pool Identification (if more than 1 pool/spa at sitp): ?r-v7e9 Facility Address: L/22 j,fV__2." Zip: St< City: Owner Name: Owner's Phone Number: Owners Address City Sc. Zip Pool cOnStruCted on or after January'''. 2010?: 13 Yes &NT- Pum ati on Recirculation 0 Jet! Booster Pump 1,/ Make/Model .,./14"//r/VO 3t) H.PV-C Make/Model H.P 0 Other Pump: H.P Feature PUMP Make/Model Make/Model H.P Main Drain (Includes All Suction Outl Excepk Skimmer Equalizer Lines} Manufacturer Of approved drain cover. in-cr/77"- Model Number . car ArfrAnstall date 6e. / --M GPM rating: Floor c,?//7i9 all Installed on 0...Pitrors 0 Wall Manufacturer of approved drain cover: /V '1. Model Number: Install dale GPM rating: Floor Wall Installed on o Floor 0 Wall Main drain/Jet suction pipe size is inches. Check One; Split main drain(s) (Minimum 3 It. 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) Single drain — Not unblOCkable (one of the following secondary devices required: safely vacuum release system, suction limiting vent system, gravity drainage sys(em, 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: o ATSM F2387 0 ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license 4(óT3' e/6/3- with classification Or a California State Professional Engineer license # with qualified experience working on public swimming pools and lhat the information . provided above is true to the best of my knowledge. I understand that if] improperly certify this information, I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health & Safely Code Section 116064.2. Company Name: Stale: ....:- Zip Code: gs5-2,:e2 Contractor/Engineer Phone Number, dP7 23‘71..W.,..?ge? Cell Phone Number: Contra ngineer F Nu ber: E _ ..-, .---- ..- ..-• /--0. Cont or! Engineer name (PRINT) Contractor ILengineer- name (SIGNATURE) Dale For a complete text of the law, visit: http://Info.5en.ca.gov/pub/09-10/bill/3sm/5b_1001.1050/ab_1020_bill_20091011_chaptered.pdf Contractor/Engineer Name: Company Address: f y1/ 4e2 City: