COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

NOV. ti. 2010 9:21AM DATE: DER " "' ' Com 1.pllance r'omi " Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NO, 6184 P. 2 NOTE: Use one form for each pump, or multiple Pumps under tha 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 11084.2. 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. Faclity Name:,[L�j_pool Identification (it more than 1 pooVspa at She): / me Facility Addres541. : �/.�� City: Ste"I( Zip - Owner Name: OWner'e Phone Numher. Owners Address City St. _Zip Pool constructed on or after January 1, 2010?: 13 Yes o No PumWformatl�bn eci[?'R 'rculathm um O Jet/ Booster Pump MakWModel i/" 0 H.P� Make/Model ❑ Feature Pump Make/Model H.P Make/Model H p Main Drain Includes All suction Outio Exce t Skimmer Equalizer Lines Manufacturer of approved rain cover Model Nu GPM date• —� GPM rating: Floor 3/b Wal Installed on 1?'Froor O wallManuf' GPM rating: of app v drain cover. Fr Model Number. Install date:—Y-1-3 GPM rating: Floor Walt Installed on 0 Floor tWdall Main drain/Jet suction pipe size is _ inches. Check One: ❑ Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) R'Sing 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 en rlxim agency) Type of secondary device Installed: Install dale, Manufacturer of approved device: Model/Part Number. Safety vacuum release system bears the following performance standard markings: o ATSM F2387 a ASMF/AN31 eland*._ _A1 n 10 1 aaimrner eouanzer Llnelsl Manufacturer of approved suction fi8ing: 44 Model Number. _Install date GPM rating GPM rating: Floorv_,�jk� Wall Installed on -❑ Floor d ^wall Skimmer equalizer line(s) pipe size were found to be inches Numberpf Skimmpre• 1 I declare that I hold an active California State Contractor license #, with classifications 5" ? or a California State Professional Engineer license # with qualified experience working on public swimming pools and that the information provided above is true to the hest of my knowledge. I understand that if 1 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 1160642- Contractor/Engineer Name: Company Address: City: ContracodEngineer Phone FAX Number; wnuau r engmeer name Fora complete text of the law, visit Company Name: state:.Z 4L Zip Code: — Cell Phone Number. FMffKlALdy 14.21110