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of l California Department of Public Health Compliance Form Anti-Entrapment Devices and Syste'ms for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 INSTRUCTIONS FOR COMPLETING THE COMPLIANCE FORM • Use one form for each pump or multiple pumps under the same drain cover. For example, a spa with a recirculation pump and a jet pump each with their own set of split drains that terminate under a different drain cover will require two forms. However, two pumps with split drains that terminate under the same drain cover will require only one form. • All sections of the form must be completed. • Print legibly. • Return the completed form to your local Environmental Health Department. I. Site Information - -A. Facility name--- name of facility or DBA (e.g. Oak Glen HOA;Palms Apartments), B. Pool Identification-description of the pool which will identify it when there is more than one pool on the property. C, Facility Address-address, city, state, and zip code of the facility where the pool or pools are located. D. Owner's name-owner, owner's representative, or corporation name. E. Owner's address-address, city, state,zip, and telephone number of the owner or owner's representative. F. Indicate if the pouf was constructed on or after January 1, 2010. II, Pump Information A. Identify the type of pump that is connected to the drain. If two pumps terminate under one set of split drains (e.g. one side of a split suction drain is used for both a recirculation pump and a jet pump), describe both pumps. For each pump, provide the make, model number, and horsepower. Remember, complete a separate compliance form if the additional pump is connected to a different drain cover. III. Main Drain(Includes All Suction Outlets Except Skimmer Equalizer Linesj A. Provide the manufacturer, make and model; and the date the drain cover was installed. B. Provide the floor and wall flow rating in gallons per minute for the drain cover. Note: If there are two different drain covers (e.g. one on the wall and one on the floor), there is space on the compliance form to complete drain cover information for each drain. C. Indicate the size of the pipe terminating at the main drain or jet suction. D. Check a box to indicate the configuration of the drain. 1. Split Main Drains-means there are two drains that are hydraulically balanced and symmetrically plumbed and are separated by a distance of at least three feet in any dimension between the suction outlets. 2. Single Drain-Unblockable means there is one drain approved to be unblockable so that a human body cannot sufficiently block it to create a suction hazard. 3. Single Drain -Not Unblockable-means there is a single drain which can be sufficiently blocked by a human body to create a suction hazard. This type of drain must be protected by an approved safety vacuum release system or other equally or more effective system. Provide the type of device installed, manufacturer,model, and indicate which type of performance standard is marked on the device(ASTM F2387 or ASMEIANSI standard Al 12.19.17). IV. Skimmer Equalizer Line(s) A. Provide the manufacturer; make and model; and the date the drain cover was installed. B. Provide the floor and wall flow rating in gallons per minute for the drain cover. Note: If there are two different drain covers (e.g. one on the wall and one on the floor),there is space on the compliance form to complete drain cover information for each drain. C. Indicate the size of the skimmer equalizer line pipe. D. Indicate number of skimmers. V. ContractorlEngineer Certification Section A. Enter a valid California State Contractor's license number. B. Enter the Contractor's license classification. C. Or enter the California State Professional Engineer's license number, if applicable. D. Enter the Contractor's-/-Engineer's name and the company they are working for. E, Enter the company address, city, state,zip code,telephone number, cell phone number, FAX number, and email for the Contractor- /-Engineer, F. Print the name of the Contractor/Engineer. G. The Contractor or Engineer must sign the form. H. Enter the date the form was signed. Revised:July 14,2010