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APPROVED BY: California Department of Public Health Compliance Form • Anti-Entrapment Devices and Systems for Public Pools and Spas OFFICE USE ONLY DATE: Health and Safety Code Sections 116064.1 and 116084.2 NOTE: Use one form for pact: num or multiple bumps 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 116084.2. Under Section 118064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool shall file this form within 90 days following the completion of construction or installation of and-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: 11 f ?Arty 6 Stet.48.5 Will Pool identification (if more than 1 pool/spa at site): Facility Address: ago 51 I bey+ city: Et.; Pod, St CA. Zip: Owner Name* Owner's Phone Number Owners Address City St. Zip Pool constructed on or after January 1, 20107: 0 Yes 0 No Purge Information :at-Recirculation Pump it. ,,, 0 Jet f Booster Pump Make/Model ri4+tetir tie ptate4 le H.P 3 Make/Model H.P 0 Other Pump, 0 Feature Pump Make/Model HP Make/Model H.P daln Drain (includes All Suction Outlets Extent SitImmer Equalizer Lines) Aanufacturer of approved drain cover ,,4@J41 Ste" ' Model Number 33C0FLF gist Install date 10131 / /2 3PM rating: Floor 3U-0 Wall Installed on afoot* 0 Wall Aanufacturer of approved drain cover Model Number: Install date 3PM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is inches. Theck One: 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) Single drain- Unblockabie (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 snore 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 following performance standard markings: 0 ATSM F2387 0 ASMEJANSI standard A 112.19.17 Sidra:nor Equalizer Linefel Manufacturer of approved suction fitting: AQUA Shur Model Number B Install date 10/3/1 1,2 GPM rating: GPM rating: Floor li'S- Wall ei si Installed on 0 Floor JerVal ci I II Skimmer equalizer line(s) pipe size were found to be 1 I LA inches Number of Skimmers: a THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFIACTURER'S INSTALLATION RE9UIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license # 910541 with classification E -S3 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 California Health & Safety Code Section 116064.2. Contractor/Engineer Name: Company Name: C#54Diern Pool; 4-' 9-ert4otail sii Company Address: 5-?00 Olokistor RA City: Ceres ! .. ..., , Zip Code: 9.5307 ... State: C. A • Contractor/Engineer Phone Numbs a 00 S3 t- Isk3 01:. Cell Phone Number: Contractor Entn_ear FAX Number slogd a 7- 4,SP? Email: RawC.4.4151N P Calk 6) 401.(36, 1. Illrbel jiteeltiffi•A .4akoo• PVC, "IAD& ntrector / Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) Date For a complete text of the law, visit: http:Ilinfo.sen.ca.gov/pub109-101billiaerniab_1001-1050fab_1020_bill_200131011_chaptered.pdf ReMset July 14. 2010 O ON