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07L20/2011 19:28 2099421925 MCMASTER CONST PAGE 01/03 may. 10 all 11:urim Dat JJdgUln vOUnly ru I; Y I• [ L , LA CaliforniaDeparbnent of Public HealthCompliance FormsAnti-Entropmenl Deviceend Systems far Publle Pools and Spas Health and Safety Code Sections 116064.1 and 110964.2 - NOTE: Use one form for each Puma or multiple Dumps unbar the same drain cover. Air SECTIONS OF TH15 FORM MOOT BE COMPLETED. This form L• t be used to verily compllarrce with modifications Pursuant to the new Health and Safety Gude sections 11 064.1 and : 116064.2. On, er Section 116066.2 (a) of th. Haahh and aerety coda, effective January 1, 20to, The owner of a public swhT mIng pool shall file this orm wltnln 30 days following the 6omplation of rwastruc0on or Installation of anti -entrapment devices or j y+tams in ' swimming po, Is. Cantaat your local Environmental Health Department and Building Department for arty necessary plan ap travel and permits prior construction or m .dal. Site Informatk I1�� IL / �. Faclllty Name: F[ e- / rte4 � A Y ( Pool Identification (if more them 000Vcpa at site): FacllltyAdtl Zia 'v!'R Gty:�'[taC,K.I�/{` St Ip: Owner Name- Owner's Phone Number: 9 x?' ( I Owners Addres 1 .7767 r-isorzt JD r . _City Q St. _ zip vr' f PD01 cor stfucle Ion or after January 1, 20107: O Yes NO Pump Woodall n i 0 Recirculathi in Pump Ac O Jet I Booster Pump MvWModel I ''r M.P �'� MaKBrModel H.P ❑ 00ner Pum : O Festal" Pump MalretModel H,P MakelModel H.P Mal Drain Inc udes All Stall Oudgjq pill elklmmorEqualizer Lines u Mam1faclurer of prrA--I dmin cover:v Model Number Install dale GPM rail ng: FIN Well C Installed on ;(Floor 0 W211 Manufacturer of proved drain cove[ Madel Number. Install date GPM radmg: Flo r Wall Inshllod on 0 Floor 0 Wall Main dreiNJet suction pipe size is if Ones. Check One: O Split n aim drains) (Minimum 3 R between covers, hydraulically balanced and aymmetr tally plumbed) 0 single draln - Unblockable (size and shape that a hurrMn body cannot sufficiently block to create a suction entrapment IIngle Oraln - Not unbloekable (Oreo of the following eacendwy devices required: amity vacuum release system, auction limi ong vent eys gravity drainage system, mp shut-off tem, or other equally or more effective system approved by an rely ag y) Type 1 eecondary device installed.- Install Manu tuner of approved device:ModeIIPM Number SONY vacuo n release system bears the following pedommrlee standard markings: O ATSM F2367 O ASMEIANSI standard A 112 0.17 Skimmorritu liter Lin MOnuhdufer 'approved suction fitting: 7 U �L�t Model Number SAx Z• Inslalldaie GPM rating: G M rating: FkbWja r -G92 War. C10".1 Installed an ❑Floor Well Skinner aqua zer line(s) pipe size wore Pound to be & Indf�es Number of Skimmers; 2 THE AB VE HA BEEN FIELD VERIFIED TO COMPLY WTH ANUFAC URER'lWTAILLATION REQIJIRErtENTS By THE IN TALLER C r or a CoMorrila ale I declare Iha1 I oW?n active (�IllOrnia Stale Contractor lipomas N 'Milt classification Profesebnal E gineer license a with qualified expenenre working on public swimming pools and that the inform fico provided abs is true to the best of my knowledge. I unoemand that y I Improperly ceNfy dile information, 12hall be subject to pot al diadplina 9 on al Iha dilicrello oftw lim.ing outhedly in accordance with Coliforms Health 8 SOWGod@ Section 116D042 _ c �r� Contractor/En inoer Name: /ZG i"� Company Name: City state: / �� $ Code: _7- Contract r/E !near Phone Number. QZ r ll phone Number. Cont dorfE ineer FAX Number: �4 E aft G _ Contra r I EOglneername (PRINT) COntrador/ Engirreer name (SIGNATURE) Dale tO7e_biN_700p1011_ haptertd.dl For a ae Wait Of the law, visit h1101fnfo.sen-ea�wb fpuPoB�tgbllVsam/.b 1001.1p$pJplb_