COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

APPROVED By California Department of Public Health OFFICE USS ONIy Compliance Form Anti-Entrapmenl Devices and Systems DA7E� for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each Dumb or multiple Dumps under the Sarnedirain 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 10 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. - _...._..� U 1 cox Facility Name: Pool Identification (it more than 1 pool p at siley, ! G•' Facility Address: City: ��0 Lf Owner Name, Owner's Phone Number: St: _Q&_ zip:_ 4 Owners Address Pool constructed on or after January 1, 2010?: O Yes {i No — Zip 'ump Information kf Make/culati n pu O Jet I Booster Pump .LL14I.A[d Pilo i _H.P 1 �% Make/Model 0 Other Pump: ~-P Make/ModelH P O Feature Pump Make/Model H P fain Drain Includes All Suction Ou lets E ce t Skim er E u liter Llnes lanufacturer of approved drain cover: L( (A S-} pr_ Model Number: LULL �� L� __ tt 1 install date _ I I IPM rating: Floor �� _ Wall—L! ��` Installed on lanufacturer of approved drain cover: ID'FIOor O Wall Madel Number; !hr rating: Floor Wall Install dale Installed on O Floor O Wall Main drain/Jet suction pipe size is inches :hr One: J Split main drain(s) (Minimum 3 h. between covers, hydraulically balanced and symmetrically plumbed) )O Single drain - UnbloCkable (size and shape that a human body Cannot sufficiently black t0 create a S4,100n 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 -oft system, or other equally or more effective system approved by enfor�emens aoency) Type of secondary device installed: Install der= _ //-�.S %O Manufacturer of approved device:,�'�-r}r ModellParl Number A !' Safety vacuum release system bears the following art i1n V n IOC" 9 P o ante standard markings: O ATSM F2387 j�ASME/ANSI standa,o - , t2.tg.77 ..__ ._ Manufacturer of SPM rating: G�rP Skimmer eoufli: 1 fitting: S l SMA! Model Number:_ 'IO 6Q At 9 Ait Install date size were found to be Installed on 0 Floor 0 Walt Number of Skimmers: ) f8 an active California Stale ConVactor license a ulncmpNis By TME INSTAI with classification Or a California State neer license !C 1yy with qualified experience working on public swimming pools and that the information IS true loth¢ best Of my knowledge. I understand that ill improperly Certify this information. I shall be subject to potential ,n at the discretion Of the licensing authority in accordance with California Health 8 Safely Code Section 116064.2. :ontractor/Engineer Name. -Ire :ompany Address: =ontractor/Engineer Phone Number: :onlraclor/Engineer FAX Number: J � Con rot / En ir, er name (PRINT) or a complete t xt of the law, visit ht0o://info &P. ea ...., 6i9:d69d LIOLBL00021:01 Company Name: State: -44`_ Zip Code: _ Cell Phone Number: 1001-105011 e Date 11chaptered.pdf RedSe M, 1/, 20,0 ObIIL9S9% 0tITL9S9TG:w0JA 2bt01 TT02-1:70-NCf