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APPROVED BY: w-alifornia Department of Public Heaitn OFFICE USE ONLY Compiiancc Form DATE: 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. 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.ianuary 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. 4Pool Identification{i mi e than 1 pool/spa a }: J - Facility Address: ^ City: �' S(' zip: r Owner Name' Owner's Phone Number. Owners Address City St. Zip Pool constructed on or after January 1,2010?: o Yes ;'�No ��..rYtiV✓p � + Pumr'information Recirculation Pump Jet/Booster Pump Make/Model H.P MakerModei H.P Other Pump: E Feature Pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outlets Except Skimmer ualizer Lines) ^ �, ivianufacturer of approve drain cover: .%< _Model Number: Install date — .+ GPM rating: Floor > Wall Installed on ><Floor E Wall Manufacturer of approved drain cover Model Number: Install date GPldl rating: Floor Wall Installed on ❑=1oor i-�Wail Main drain/Jet suction pipe size is_ _inches. Check One: ❑ Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ,P<'Single drain-Unbiockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) _i 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: Modei/Part Number: Safety vacuum release system bears the following performance standard markings:❑ ATSM F2387 ::] ASME/ANSI standard A 112.19.17 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#_$24920 with classification C61_D35 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 it 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: Timothy I= HPmplemap Company Name: Hempleman's Pool Cures Company Address: 11749 Sawyer Ave City: Oakdale State: CA — Zip Code: 95361 Contractor/Engineer Phone Number: 209-$47-3305 Cell Phone Number: 209-814-6 5 Contractor/Engineer FAX Number. 209-847-3305 Email: TimQHemplamans cam Timothy E Hemnleman — Contractor 1 Engineer name(PRINT) Contractor I Engineer name(SIGNATURE) Date For a complete text of the law,visit http:lrinfo.sen.ca.gov/pub/09-10/bill/asmlab_1001-1050/ab_1020_bill-20091011_chaptered.pdf