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APPROVED BY: California Department of Public Health O[FICE USE ONIV <br /> Compliance Form <br /> DATE: Anti-Entrapment Devices and Systems <br /> for Public Pools,and Spas <br /> Health and Safety Code <br /> Sections 116064,1 and 116064.2 <br /> NOTE: Use one form for each Dump or multiple pumps under the samedrain cover, <br /> ALL SECTIONS OF THIS FORM MUST BE COMPLETED. <br /> This form is to be used to verify compliance with modifications pursuant to the new wealth and Safety Cole sections <br /> 116064.1 and 116064.2. Under Section 116064.2(a)of the Heanh and Safety Coda,effective Jan and <br /> Sri ery c the owner of <br /> a public swimming pool shall file this form within 30 days following the compieNon of construction .1 installation of anti- <br /> Department <br /> forandevices or systems in aw moven amming pools. Contact your local Environmental lleanh Department and Building <br /> Department for any necessary plan approval and pemnks prior to construction or remodel. <br /> Site <br /> b formation <br /> Fefity Name: /, f � yf5 _pool ldentaica ion dm Thant <br /> Fedliry Address: �L 3 US � L poOUspa al site):, <br /> —7� <br /> Owner Name: ��,� •H Jl+�p Qtr. S�L�—Zip:_ --5 <br /> Owners Address ��l,0.,r /L,n'2 Owner's NIS;-E+-it-�leo��J¢-CJ/..��.L'�� <br /> Pool constructedon or after January 1,2010?:- -_ O yes `� —St. WP <br /> _Puma Intotmali0n <br /> n Recirculation AAoqt—: Pro <br /> Make/Mcdel_ R Ql N.p f O Jet I Booster Pump <br /> O Other Pump: Meke/Modef <br /> Makelmodel -' .—H P O Feature Pump H.P <br /> Maka/Moder '�-�—H.P <br /> in rain I-- I ��-•--- <br /> Manufaeft""01 a PProred drain kfs be <br /> Sit b�u <br /> IrmeSS uc. � 0GPM rating:FloorModel Nump!d ! <br /> ap` ttied por < _ usw <br /> n date <br /> Manufacturer ofproved drain corer. Flall <br /> --- <br /> GPM rating:Flow` del wau MoNumber Install date <br /> Check one: __ installed on p Fbcv D wee Main ftWiel SUCUM pipe size is—_htd+ea. <br /> O Spill mall.dmin(a)(Mndmum 3 a,between coversle ' .hydrauscelty,balanced and S b Phrmbad) <br /> osingle drain GraI - w6lodtebp Com ol��nowlitit secondary�f m^nol auX'tindy block to create a suction entrapment) <br /> system,gravity damage syslem•auto shut-off f eericee required: aatey vacwyn rakase System.suction His"vent <br /> Type Of secondary device brsuasd: Du'n0 $plant,or other equally or more eseelve system approved by enforcement agency) <br /> Manufacturer of apwm,ad da,ree: install date <br /> Sahtty vacuum release system hews IttE lonowing Pedomgnoe standard MaJeePan Number, <br /> ASMFJA _ <br /> TME AB Y•ccc :0 ATSM F2367 O I�SI a <br /> N t^yERIFtEo m rrww v w tendert A l 12.19.17 <br /> 1 deaare roar t rt010 an eeeve CeBomia `NtIaFWe "eTALLAnON aFMewcY <br /> 6tab COnvaclor Ifcertse p NTS BT THE tNg1At= <br /> ProfeesronN Engineer Iktertae p -- !tilt tlasetTica6pn Qr a California State <br /> —�,..`_whir VOati6ed espettancg wpklr�en public awitreMng P0015 and that the Information <br /> provided above is fore ro the beat d my knOwtedge. I uMerstarp that a 1 tmpr <br /> diStipretary salon al the lrspg0on Of the ilcendn IlUlllpri in accordance Mth Calyywnie i kallh)i albs.I shag be sublecl to Ddem41 <br /> COntraaot/Engineer Noma. /�? ' � Coda section 116053.2. - •_ <br /> COmparry Address: CpnPany Name:. 7 , Ll S Ofd s;-Spey <br /> Contraaor/Engkteer Phone itate:,f�_ _-2b Code:, . <br /> COnlraaor/E Number Cap Phnnst Number. <br /> ngineer FAX Nu~ . <br /> •- Email: •"� <br /> Convaaw/Engineer name(PRINT) —'.. - — <br /> rat 6 complete text of the P. Contractor/E re name(SIGNA- T 0--- ak--- <br /> Few.viStl, till J/inro.sen.Ce.gov/pub/09-tOJbllUasm/e b_7ool-1030/ab 1020 bill 20091011 chaPlered.pdf <br />