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APPROVED BY: DATE: OFFICE USE ONLY Contractor/Engineer Name: ....re Company Address City: Contractor/Engineer Phone Number: State: (4 Cell Phone Number: Zip Code: krarn ___ILL3 • 1-49) 0 triak'6tor E er e (SIGNATURE) Date -10/billiasm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf California Department of Public Health Compliance Form Anti-Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 1160642 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 Intgrmation Facitity Name: fity AddresS: Fri tAN 1Y)01(t Faci 5‘100,, a Owner Name Owners Owners Address City St. Zip Pool constructed on or after January 1, 2010?: 0 Yes .4 No Pi no Information Recirculation Rump I 0 Jet / Booster Pump Make/Model ,I1.1 g, I L(00 H.P I/ < Make/Model H.P C . One: Manufacturer of approved drain cover: GPM rating. Floor Wall Installed On q Floor CI Wall Main drain/Jet Suction pipe size is Main Drain Includes All Suction Outlets r t Skim er Equalizer Lines) Manufacturer of approved drain cover GPM rating: Floor 20 0 la al Model Number: (DJ( Instatl date ill-- b ir Wall Installed on 4silf loor 0 Wall Model Number Install date : inches. 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) 0 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: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pump shutl System, or other equally or more effective system approved by enforce Tent agency) T • - .f secondary device installed: . ki .'"-j Install date t-/ ..-- 0 ,,,,,, t: iii cturer of approved device: ...c171 114,Le Model/Part Number: Safdtvactftim release system bears the following performaAce standard markings: 0 ATSM F2387 •I• • SME/ANSI standard A 112.19.17 ---- -,/i' SkimrneKtifCCipzer Line(s) Manurktureltapproved suction fitting: (4/1"1 nizevi- . Model Number: __cpiX / 4.6- Install date kill- Ab(o ,., _ •••,,....-- • .,,., 2-00 Wall 11 0 Installed on 0 Floor YNall GPM rant,ing—GRAA rating: Floor Skimmeiswattler line(s) pipe size were found to be inches Number of Skimmers: _ -2--- Tat, A-BOVE HAS BEEN FIELD V RIFIED T COMPLY WITH MANUFACTURER'S INSTALLATION REOLIIREMENTS ElY THE INSTALLER I declarejtie*I l'•.d an active California State Contractor license 4 -7<cdey f with classification GO or a California State Profess'. , - -i•f• eer license 4 Ait with qualified experience working on public swimming pools and that the information provided 1411.1111°' 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 8 Safety Code Section 116064.2. Lec ii°e P0x2i/AtiPt a - Contractor/Engineer __ FAX N e umber 42 7.-, , ,to ckf ,,i,/ Con rNe EniR r name (PRINT) CFora complete text Of the law, visit http://info.sen.ca.gov/pu Owner's Phone Number 244 It i771/ 0 Other Pump. 0 Feature Pump Make/Model H P Make/Model HP Company Name: Pool Identifica City: ion (if more than spa at site)' 690 )1- St: (4k, Zip: 9 5 Zi 0 Rimed July 14. 2010 Ot7TTL9S916:woJd Tb:OT IT02-i70-Ntlf LIOL8D76021:01 OtITL9S9T6 6,„t7 :a6ed