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APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form DATE: Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each pump or multiple pumas 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: _ Facility Address:, Owner Name: _ Owners Address Pool Identificatio (if more than 1 0o spa at site): _-1"W— _City: St: rA- Zip: 99Z I Owner's Phone Number:_ _City _ t. Zip _ Pool constructed on or after January 1, 2010?: O Yes 'Jif No Pu Information Recirculation P p ❑ Jet/ Booster Pump Make/Model A✓fXlp .4—H-P1i Make/Model ________ H,P ❑ Other Pump: _ _ O Feature Pump Make/Model _ _H.P Make/Model HP Manufacturer of approved drain cover: iffl u.A Cd"AY GPM rating: Floor I aQ wall GPM of approved drain cover: I— Installed on Model Number: I& 401 Install date Floor O Wall _ Model Number: _Install date _ GPM rating: Floor Wall____ Installed on 0Floor o Wall Main drain/Jet suction pipe size Is inches. Check One: o Split main drain(s) (Minimum 3 ft. 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) Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pum shut-off system, or other equally or more effective system approved by enforcement �agency) Type of secondary device Installed: _Install date d Manufacturer of approved device: _Qh Model/Part Number: C flod7 Safety vacuum release system bears the following perfor ance standard markings: o ATSM F2387 o ASME/ANSI standard A 112.19.17 1 hold an active CaliforniaState Contractor license # -715 r with classification 4O_ora California State jrtgineer license #�,j{� with qualified experience working on public swimming pools and that the Information true to the best of my knowledge. I understand that if I Improperly certify this information, 1 shall be subject to potential &t the discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. Company City: _. Phone Number. Contractor/Engineer Name: State: ?' /} Zip Code:/ �X _ Cell Phone Number: _ 7�CJ� JG% OGtr�( �� Contracto / Engineer name (PRINT) Cinf4orlngi ee naF me (SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/0 l/asmlab_1001.1050/ab_1020_blll_20091011_chaptered.pdf