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APPROVED BY: DATE! Califomia Department of Public Health 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 Puna of multiple Pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to he used to verity 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. Facility Name: f 1 t Y Y1 1 li Y I 101 I Y Pool Identification (it more than 1 pool at site) J�W Facility Address: �` ��1 t �,Ifr� N City , Cn C�e'�D St: Zip: 4 S lid _ Owner Name. Owner's Phone Number: Owners Address Pool constructed on or after January 1, 2010?: Cl Yes , ( No y Zip -ump mrormaUon - Recirculation P��t^p h O Jet I Boaster pump Make/Model f 1al.&I A,}c,t �)y(7� H,P ( L? Make/Model t� H.P O Other Pump: O Feature Pump Make/Model H,P Make/Model H p Iain Drain Includes All Suction Outlet E ce 1 Skim er E u liar Lines!1 � �(� lanufaclurer or approved drain cover: Ia U. S+OT Model Number: t.. Q�In5tal1 date :PM rating: Floor 1o© _ Wall_ Installed on !Vloor O Wall lanufaclurer of approved drain cover: V Model Number: Install date :hr One, ;PM rating: Floor Wall Installed on 0 Floor O Wall Main drain/Jet suction pipe size is �� inches J Split main aram(s) (Minimum 3 It, between covers, hydraulically balanced and symmetrically plumbed) )OSingle drain - Unblockable (size and shape that a human body cannot Sufficiently block to create a suction entrapment) Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pump shut-off System, or other equally or more effective system approved by enforqement agency) Type of secondary device installed: IInstars d��= Manufacturer of approved device: l A ,+ c ModellPan Number Safely vacuum release system bears the fallowing peAo ante standard markings: 0 ATSM F2367 AVASME/ANSI standaro ...12.19.17 Manufacturer of 3PM rating: GP Skimmer equal 1r � �1 filing: S r.rvaf�a•'— hlA4 NIX Model Number: r IO Gut A A,r Install date size were found to be Installed an ❑ Floor o Wall Number of Skimmers: Ian active California State Contractor licensed / with classification or a California State rb license # t % with qualified experience working on public swimming �'-F d g pools and trial the information is true to the best of my knowledge. I understand that if I improperly certify this information. I shall be subject to potential In at the discretion Of the licensing authority in accordance with California Health 6 Safely Code Section 116064.2. :onlractor/Engineer Name. ,Ompany Address: ybl-h ity. ;Ontiactor/Engineer Phone Number: :onlractor/Engineer Con r cl / I Or a complete t xt 6/9: a6 ed LT0L81b6021:01 Company Name: State: _ %� Zip Code: ObTTL959T6 1001-10501a4 1020 bill 20091011-chaptered.pdf ROVS911 Me l4, 2010 0bTTL9S9T6rwOud 20:0T TT02-b0-Ndf