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r 05/LB/2011 10:30 5376599 PAGE 03/05 APPROVED BY f N OFFICE USE ONLY INSTALLATION CERTIFICATION Fee Paid 8 VGB DRAIN COVER & SECONDARY DEVICE FA; DATE: PR: NOTE: Use one form for each pump or multiple pumps under the same cover. 5R: For the property named TW IN A? -W-15 Date: located at &Safe09a C04,if" California, I hereby certify that pursuant to California $late Health ty Code Sec. 116064.1 and 118084.2, that an Anti -entrapment cover meeting the current standards of the American Soci of Mechanical Engineers (ASME)/ANSI performance standard and where required, a secondary safety device meeting the current ASME/AN or ASTM performance standards have been installed per the manufacturer's instructions on the; Swimming Pool ❑ Spa Recirculation Spa Jet Booster .2r Wading/toddler pool Existing Pump($): Make/Model F`0440itr Lo eo H.P 3 Ffe ; Flow (gpm) Make/Madel H.P ; Flow (gpm) _ Mein DraIOLsL. Manufacturer of approved cover: AV—Q,9 &h�K 0Z odsl/Part Number: SCO F LIFRlotl GPM rating: Floor �� ; Wall Installed on d/ Well urFloor Cover bears the following markings: ❑ "VGB 2008 or later', S e "ASME/ANSI standard ?y 112.29.8.2007 or later', "Life": Main drain/Jet suction pipe size is _ -'!a inches. Manufacturers main drain(s) sump depth requirement in inches is: ❑ Single drain - Not unbiockable (one of the following secondary devices required: 5VRS I Suction limiting vent 1 gravity drainage I auto pump shut-off/ other approved by enforcement agency) o Type of secondary device installed: o Manufacturer of approved device: ModallPart Number: SVR$ bears the following markings: ❑ "ASTM F2387", ❑ "ASME/ANSI standard A 112.19.17", NOTE: If Installing a variable speed SVR$ pump a RPM/Tlme Data sheet shall be faxed to EMD at 875.8519 fellow the Installation, (A sample form Is available from the Environmental Health Plan Review office) in Single drain- Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) G Dual main drain(s) Eouallze i s s : Manufacturer of approved cover: _outil $}4tv^ 8i1p aaS Model/Part Number: 2C.IDP4F2101 GPM rating: Floor; Wall_ Installed on a Wall W-Ioor ❑ "VGB 2008 or later", .a ;K "A8ME/ANSI standard A 112.18,8.2007 or later', "Life": Skimmer equalizer line(s) pipe size were found to be vhk inches # of Skimmers: 1 Manufacturer's skimmer equalizer line(s) sump depth requirement In Inches is: 3 e Single equalizer line ❑ Dual Skimmer equalizer Ikle(s) sump depth _Inches 0 Skimmers are connected with single line to pump. ❑ Skimmers are separately valved before pump and can be isolated. I declare that I hold an active California State Contractor license # 81`089 ) or California State Professional Engineer license C-6-5 , with qualified experience working on public swimming pools and Ihat the Information provided above is true to the to of my knowledge. I'm aware that improper certification of the above information shall be subject to potential disciplinary action at t' discretion of the licensing authority, �� S4e5% Mo�Ltc 5%9%ii _ Signet r , Print name Date Contact Name:, Phone 6a0_y Y95`99,57,man 2�ow PAYMENT DUE PRIOR TO APPROVAL CALL PLAN REVIEW AT (910) 874.6010 For a complete text of the law, visit: httoa/Info sen ca.aovloubl09.10Ibillife fab 1001.1060/ab 1020 bill 20091011 chartered df ._..._. .." 1. o..