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APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance f=orm 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 Pump or multiple 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 Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information Facility Name:�( '? 6L L A rr Pool Identification (if more than 1 pool/spa at site):FacilityAddress : 24- — —- -- i y ... __ ._ _._ .. St Zip: Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 2010?: ❑ Yes �a,No Pump Information * Recirculation Pump ❑ Jet 1 Booster Pump Make/Model H.P Z Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H,P Main Drain Includes All Suction Outlets Except Skimmer Equalizer Lines / Manufacturer of approved drain cover. OQd,J F — Model Number.kldjt(.PInstall date GPM rating: Floor_ Installed on g(Roor ❑ Wall Manufacturer of approved drain cover. Model Number: Install date GPM rating: Floor Wall Installed on ❑Floor ❑Wall Main drain/Jet suction pipe size is inches. Check One: ❑ 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) ❑ 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 data i e 01rer of approved device: Model/Part Number: Safety VctPUr.'faelease system bears the fallowing performance standard markings:❑ ATSM F2387 ❑ ASMEIANSI standard A 112.19.17 Skimmer,590MIlir Line(s) Manufacture, -,tf ap'proved suction fitting: Model Number: Install date GPM rating-GPM,s.'ting: Floor Wall Installed on ❑Floor ❑ Wall Skimmer equalizer"iine(s)pipe size were found to be inches Number cf Skimmers: THE ABOVEHAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare thdt 1'holddn active California State Contractor license# CrO�2.I with classification C;S or a California State Professional`,Engineef license# with qualified experience working on public swimming pools and that the information provided abdve.is true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health & Safety Code Section 1160664..2. Contra otvrlEngineer Name: _T��e �hi r. Com pany Name: Nr74�; c_ Z,f Rd, 1 jam_ Company Address: _ 1 q 3�, kale r�o.0 I,vF City: State: 6A Zip Code: q 5:� y0 Contractor/Engineer Phone Number: ZO �� 23+ 1&S5 Cell Phone Number: Contra ctor/E,nggiineer FAX Number: a ! S Contractor/Engirw6r name(PRINT) ntractor/Engi name(SIGNATURE) Date For a complete text of the law, visit: http:/Iinfo.sen.ca.govipubl09-10/bill/asm/ab-1001.10501ab-1020—bill-20091011—chaptered.pdf Revised:July 14.2G10