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ur.l/. 010 IU:IYAM San Joaquin County No -0652 P. 2 APPROVED BY: ialifornia Department of Public Healu OFFlGE.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 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 CAdb 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 shallff[a this form within 30 days following the completion of construction 'or installation.pf 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 Inform on Facility Name: Pool identification (if more than 1 pooyspa at site): Facility Address: ar' ,i�ue, City: /$'1#M SI: Tp: w Owner Name: Owners Phone Number. Owners Address Cfly St. _Zip Pool constructed on or atter January 1. 2010?: ❑ Yes 441e Maakke/MMoo del "" // �� HP O jet/ Booster Pump a �, /� S Make/Model H.P ❑ Other Pump: o Feature Pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction Oud Face Skimmer E ualizer Lines)/'1 Manufacturerof approved drain cover. ' M;Hir Model Number. 0A ristall date - 16) GPM rating: Floor„ Wall Installed on ho400r ItYtNall Manufacturer of approved drain cover: Model Number., Install dale GPM rating: Floor Wall Installed on O Floor O Wall Main drain/Jet suction pipe size is inches. Check One; O Split main drain(s) (Minimum 3 It. between covers, hydraulically balanced and symmetrically plumbed) O Single drain — Unblodtable (size and Shape that a human body Cannot sufficiently block to create a suction entrapment) W ogle drain — Not unblockable (one of the following secondary devices required: safety vacuum raises' system, suction limiting vent system, gravity drainage system, auto I- If system, or� or more effective system approved by enfq a (agency) ( Type of secondary device installed: Install date Manufacturer of approved device: Model/Part Number: Safetyvacuum release system bears the following performance standard markings: o ATSM F2367 O ASME/ANSI standard A 112.19.17 I declare that I bald an active California State ConpaClor license M with classTcationLr3 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 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 Califomia Health 8 Safety Code Section 1 f 6064 2. ContraclorlErigineer Name: Company Company Name: State., Zip Code: Contraclor/Engineer Phune Number, 4«/ < �/_—y Cell Phone Number: 1001.10501ab-1020_bili-20091011—aha ptered.pdf