COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

1 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 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 l Facility Name:. C d.3 e(-- At Ln�C _ Pool Identification (if more than 1 pooilspa at site), – Facility Address. ft r—(- r I y; -- —St: - zip; 45Z UA Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 20107: ❑ Yes Z No PumR Information ❑ Recirculation Pump ❑ Jet!Booster Pump Make/Model1yg H.P Make/Model H.P_ ❑ Other Pump: ❑ Feature Pump Make/Madel H.P Make/Model H.P � Main !]rain Includes All Suction Outlets Exce t Skimmer E ualizer Lines Manufacturer of approved drain cover. A4u v 5')'e1 !— Model Number: aVV& Install date GPM rating: Floor Sk I GPM Wall Installed on oWioor ❑ 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 date Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the fallowing performance standard markings:❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimm lizer Line(s) ' Manuf�ctUn5r'91approved suction fitting: Agu4t_ 5 a r� Model Number: LVX 7 w install date.3 - GPM ratinq-�Q M rating: FloorWall Installed on I,Floor ED Wall At AP 4 y tit Skimmdr equalizer line(s)pipe size were found to be inches Number of Skimmers: THE i IBQyE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER declare"that:l held an active California State Contractor license# with classification or a California State Professional Erig(peer license# with qualified experience working on public swimming pools and that the information providedAbove is,true to the best of my knowledge. I understand that if I improperly certify this information, i shall be subject to potential disciplinary actionlat the discretion of the licensing authority in accordance with California Health &Safety Code Section 116064.2, Contractor/Engineer Name: �Sc n1l 44f 1��S.�C Z_ Company Company Address: / }� A,2 de 4 Cv U C_ City: LC ctr' _ State:� Zip Code: Contractor/Engineer Phone Number: ' `C> –1 6L Cell Phone Number: Contractor/Engineer FAX Number: Z.e J f Email: r n c ,f ©d rA Z- 04 6- Contractor I E eer name(PRINT) Contractor En eer name(SIGNATURE) Date For a complete text of the law, visit: http:llinfo.sen.ca.gov/pub/09-10ibill/asmfab_1001-1050/ab_1020–bill_20091011–chaptered.pdf Revised:July 14,2010