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APPROVED BY: California Department of Public Health OFFTCE USE ONLY <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 pump or multiple Dumps under the same drain 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 Health and Safety Code sections <br /> 116064.1 and 116060.2. Under Section 116064.2(a)of the Health and Safety Code,effective January 1,2010,the owner of <br /> a public swimming pod shall file this form within 30 days following the completion of construction or installation of anti- <br /> entrapment devices or systems in swimming pools. Contact your local Environmental Ifealth Department and Building <br /> Department for any necessary plan approval and permits prim to construction or remodel. <br /> Site Information <br /> Facnty Name: / h - •Pool Idenlifica ion(if m than 1 <br /> Faclty Address:. U �� (p �qe Poatlspa et site): <br /> Gly: $-__r SL• aD:� �..-._ <br /> tTvnhn Name:_y'"� <br /> �' Owner's Pn ne Npmb&:I - o�c'i <br /> Owners Address /6 N�3 �•�_Cllr' <br /> Pool constructed on or after January J.2010?: D Yes —$t.—CA-zip <br /> Y'�`V <br /> Puma I ,fomnlbn Pro "---- <br /> fl R kelmo*on � ( O Jet/Booster Pump ^� <br /> / Meke/Model <br /> O Other P <br /> kilake/kaodel - O Feature Pump <br /> •—H P— Makalmodel H.P <br /> Main Drain flneludea All S�•�-n,•r is Elheeot Skimmer ReHaLl-InI <br /> MenUfeclUrlr of approved"I covin• •sC�y��jy��I sac )vOu <br /> GPM rating:Floor_ wag z j . 1 f4pd01 l�/Um�'• Inde date <br /> Manufacturer W approved drain cover: nateled an O Fbor , WsO .'— <br /> GPM ratio FI - mow Number. Instal date <br /> 9.Flow wall Installed on 0 Floor O was Main tlraiNJel auction i <br /> Cheek One: -- Pipe$ize IS inches. <br /> O 5 POlInme18 drain(s)(Minimum 3 ft,between covers.nydrouscely bblanced ami aymmaldway plumbed) <br /> l Side drain- UWJWkaW(aim end$nope mel a human body Cannot sufficiently block to create a out tion entrapment) <br /> ^D Not unblocitabts (one of the following secondwy devices r <br /> system,Wavily drainage system,auto pump shut-o9 system,of Ocher nOlyd d: o vaouurn,%gse system.suction 4ns'ang vent <br /> Type of Secondary devtee Insg9ed: swear er more ellephe system approved by onforcernenl agency) <br /> ManWacturerdl approved device: Instan date <br /> Salty vacuum release system Dedra Ina 101 Mod"an Nunaro1�r. <br /> law'a8 peAannapPe pendard,markiriga:O ATSM F2317 O ASME/Antil_THE A2501; MAN r standard A 112.19.17N � FyerH <br /> n eve . <br /> I datlaro that I hold on active conarnia Stay INSTnLLATIOIe crvhaaewrNTS BY TME INSTAU FR <br /> Professional E Contractor dcerhss p-- A cletsiGca6ort_or a California Sink <br /> Engineer to the a��__with ylralged espedence <br /> Provided above is nye ro W best Of my knowledge. I underaland that <br /> 11 on Public swymhing posts and Mat ere hdarmalon <br /> o1SdPlnery action at Ina diapelon Ot the$ce WWOP rlr CC"tlds khklnrmlion.1 shall be rwblecl to Potential <br /> min a�a�orderhC:e with ClMpnia`�ly Code Section 116064.2. <br /> CtmlraclpdEnginQer Name: 1. ?j't�''�� 2_Comps Name: 40 ,1 <br /> COMPSmy Address: m — - -�c� 1 0� <br /> City: >r+'�ti�- <br /> COnllabler/En ` /�' ��\ Sato:_may, ._zip code:, 9 3 3 <br /> linear Phone Number: 'F' -1 b ,6-A.P. Z I <br /> ConuaclOdE h Cell Phone Ntrnber. <br /> ng neer FAX Nmthber: Email: _ a <br /> ------------------------------ <br /> Coneaclor/Engineer name(PRINT) —' <br /> For a complete text d The ConDaclar/E�itgNeer name(SIGNATURE) pgi� <br /> lay.visit. lnllp;//info.sen.Ca.gowpub/09.1WDIIUasm/ab_7gp1-tOSOlab 1020 bill 20091011 ter chs <br /> P edydl <br />