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Compliance Form knti-Entrapment Devices and Systems DATE: 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. 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 t /�t�� 6( Q(�k'Jl .��lps r A" Facility Name: 51� Pool Identification(if more than 1 poollspa at site): Facility Address- S�j t7l FLA7h t/ / 0✓ City. J7U��0� St CA Zip: 9!5 7.1 Owner Name: .14/+R A4 L / ��i Owner's Phone Number. Owners Address city SL_Zip Pool constructed on or.after January 1,2010'1 D Yes ;91,19 Pu Information ecirculation Pup (� D Jet f Booster Pump Make/Model 1'�3Y�f LUtt-g H.P y Make/Model H.P ❑ Other Pump: D Feature Pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction OutletsExc t Skfmmef E ualizer Lines / Manufacturer of approved drain cover. T A Mo J AJ Model Number. Sb-V Z Install date l ,f GPM rating:Floor /Yd Wall Installed on )Moor D Wall Manufacturer of approved drain cover. Model Number. Install date GPM rating:Floor Wait Installed on D Floor ❑Wall Main drain/Jet suction pipe size is Z inches. Check One: )eSplit main drain(s)(Minimum 3 R between covers,hydraulically balanced and symmetrically plumbed) D 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 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 Viewing performance standard markings:D ATSM F2387 D ASME/ANSI standard A 112.19.17 Skimmer Equalizer Linelsl Manufacturer of approved suction fitting: 1 A- Ny Model Number. ";Dx Z Install date 70 f GPM rating:GPM rating:Floor Wall Installed on D Floor WeNail Skimmer equalizer line(s)pipe size were found to be inches Number of Skimmers: I THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WfTH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license# `7epl 6-70, with classification g!�—S Ior 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 uhderstand that if I improperly certify this information,I shall be subject to potential disciplinary action at the discretion of the licensing Cauthority in accordance with California Health&Safety Code Section 116064.2. Contractor/Engineer Name: / (� Company Name: Company Address: ` / rC. City: GOLFS iuL/- state: Zip Code: 67 Contractor/Engineer Phone Number. q161 — _ 6 Cell Phone Number. ContractorlEngineer FAX Number. Contractor/Engineer name(PRINT) Con cfor/FJlginee(n a(SIGNAN ate For a complete text of the law,visit http:frnfosee.ea.gov)pu 4 1 iIV m/ab_4001- 050/ab 1020 bill 20091011_chap ered.pcif Rens :JWr ib.WIG