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APPROVED BY: DATE: , dlifornia Department of Public Hear..r Compliance Form Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 OFFICE USE ONLY NOTE: Use one form for each puma or multiple pumas 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 January 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 M /2 Facility Name: niDT�� fU # 13x3 Pool Identification (if more than 1 pool/spa at site): Facility Address: %n717 PLyJH04.7E+ Q•D City: 5//CCk7UlV St:Zip: 953-16% Owner Name:�" %L Owner's Phone Number: r; C 9S i Owners Address 67/ 7 /21- yJA0ct7/ lp- City To 6-k-16 4_J St. Zip `iS 3U 7 Pool constructed on or after January 1, 20107: 0 Yes u(—No Pump Information ❑ Recirculation7 ytti.fii2-77 /r%H.P '3l`/ Make/Model l7 Make/Model m Booster Pump H P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P main Uraln 11FIGMUWU Flu JY4YVu vuuow Gnbc a.anunu.v. Manufacturer of approved drain cover: C) % Model Number: V53uo Install date ✓ �� GPM rafing: Floor I a3 Wall Installed on ) Floor ❑ Wall Manufacturer of approved drain cover. �� Model Number: �%i 3L�� Install date 'T _V Manufacturer GPM rating: Floor L 3112 Wall 1 r7-5 Installed on ❑ Floor x Wall Main drain/Jet suction pipe size is 1 y t- inches. Check One: 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ❑ Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) )ILSingle drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pumps ut-off system, or other equally or more effective system approved by enforcement agency) Type of secondary device installed: V ( 5 Install date a otCi Manufacturer of approved device: 10 b V Model/Part Number: Safety vacuum release system bears the following performance standard markings: 0 ATSM F2387 X ASME/ANSI standard A 112.19.17 I I r an active California State Contractor license # with classificationl S i or a California State f a n with qualified experience working on public swimming pools and that the information pr Id a o of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disciplinary act / n of the licensing authority in accordance with California Health) & Safety Code Section 116064.2. Contractor/Engineer Name: LG /5 JIMc�.J � Company Name: /tzPb aL'E' Rol -5 Company Address: 7 (OW -1 City: 5/}0 S05E Contractor/Engineer Phone Number: contractor/Engineer FAX Number: - GuIS J149imez Contractor / Engineer name For a complete text of the law, visit: _ State: C Zip Code: y S O-3 _ Cell Phone Number: U_ t 3� Email: 1w 1 i exeZ . IID lb DC�c�S • l f� �-3 • moo/ v Engineer name (SIGNATURE) Date m1ab-1001-10501ab_1020-bill-20091011-chaptered.pdf