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APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form Anti -Entrapment Devices and Systems DATE for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each bump or m_ulliple pumps 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 Oepanment and Building Department for any necessary plan approval and Permits prior to construction or remodel. Site Information �i r ��—City Facility Name.j l Cyt (2 V (l,(/Q ool Identification (if more than 1 pool pa t site):FacilityAddress �� o��'2 �St: 2i Owner Name: P' Owners Phone Number. Owners Address I' - Pool constructed on or after January 1, 2010? 'ump Information O Recirculation Pump Make/Model Zip ❑ res 4 No .P "'111 tp Jel I Booster Pump -72 Make/Model tH P J . O Other Pump: 13 Feature Pump Make/Model H.P Makeimodel H.P Aain Drain (Includes All Suction Outlets Except Skimmer Eoualizer Lineal tanufacturer of approved drain cover: Ar-�'u)5hF Model Number �I Install date 3PM rating: FIOor !y�/_ U Wgll_ Installed on �fFlpor O Wall lanufaclurer of approved drain cover Model Number: Install date TPM rating: Floor Wall hr One: Installed on o Floor O Wall Main drain0el suction pipe size is inches J Spltt main dran(s) (Minimum 3 h. between covers, hydraulically balanced and Symmetrically plumbed) O Single drain - Unblockable (size and Shape that a human body cannot sufficiently block to create a suction entrapment) j� 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 enforcement agency) Type of secondary device installed: Install 0 to Manufacturerapproved device: t ModeUPan Number: Safety vacuum releasese system bears the following pOAormance standard markings: ❑ ATSM F2387 ASME/ANSI standard A 112.t9�.t 7 Skimmer Eoualizer Linefsl o �pU Manufacturer of approved suction fitting: �OIYV e / I I r VIn'� Model Number: Install dale 3PM rating. GPM rating Floor Wall Installed on ❑Floor q Wall Skimmer equalizer line(s) pipe size were found to be air inches Number Of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED Tn cnum v ung.. declare [hat I hold a dive California State Contractor license p INLLNIIVN REDDIR MENTS BV THE INSTALLI � with classification G Or a California Stale 'rofessional Engin e N _ with ualified experience working an public swimming )rovioed above i �� q g D 9 Ooplll and that the information best of .- knowletlge. I understand that it I improperly certify this information, 1 Shall De subjeCt to potential fisCiDlinary act I 1 cretiOYrn'of the licensing authonly in accordance with California Health ii Safety Code Section 115064.2. .Ontraclol me. V e_ Company Name: l� -ompaR S Phone Number: lunrracrarltnglneer FAX Number: 'Uh } b-j� Con r CIO / En in er name (PR(NT) Or a complete t sd of the law. visit: httn Rinfn ten ..— G,):aapd LTOLBL0602I:01 State: —c4- Zip Code: Cell Phone Number: y� g� Iter7lgfFte (SIGNATURE) -AA 3 Dle 'ab 1001.1050/ab-1020 bill 20091o11_chapteered.pdf Revised July it. 20ta ObTIL999% 0tTTL9S9i6:w0ud £b:OT TT02-00-Ndf