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ng I- Lr. Lvl_u Ill: IWill% ban Joaquin Lounty No. 0652 P. 2 ti APPROVED BY' lifornia Department of public Health OFFIGE.USEONLY Compliance Form' DATE: Anti-Entrapment Devices and Systems for public Pools .and Spas Health and Safety Corte Sections 116064.1 and 116064.2 NOTE: Use one form for each ujnl or multi le earn s under the sande.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 Gods st;t:tions 116064.1 and 116064.2. Under Section 116064,2(a)of the Health and Safety Code,effective January.l,2010;th-e owner of x a public swimming pool Shall•file this form within 30 days following the completion of construction or instaliatt'on;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. ---------------- �La Informa[ian Facility Name; t Pool identifCatio�}(I more than 1 pool/spa at sag): 40 Facility Address: city:_ t7dl' �Zi g�� Owner Name: p:- Owner's Phone Number: Owners Address - City _ zip constructed on or after January 1,2010?: O yes if f � Pum rtmation esirculalio ump ? ❑ .let 1$ooster pump MakeJModel� , (/ �H� � Make/Model H P 0 Other Pump, ❑ Feature Pump Make/Madel H.P Make/Model H.P Main Drain Includes All Suction Outleb Exce Skimmer E ualizer Lines Manufacturerof approved drain cover. --Model Number GPM rating:Floor ¢ Wail �� 52� Install date Installed on [floor a Wall Manufacturer of approved drain cover: Modef Number. install dale 6 119j le GPM rating:Floor Wei) / Check One. + Installed on ❑Floor OWSA Main drairdJet suction pipe size is inches. O Split main drain(s)(Minimum 3 ft bdtween covers,hydraulically balanced and symmetrically plumbed) a Sdrain-Unblockable(size and shape that a human bogy cannot sufficiently block to create a suction entrapment) 'Y'a rn a drain-Not unblockable (one of the following secondary devices required: safety vacuum release system,suction limiting vent system,gravity drainage system,aut mp t- system rot qually or more effective system approved by Suction c en agency) . Type of Secondary device installed: Install date ;� Manufacturer of approved device: Modef/Part Number: Safety vacuum release system bears the following performance standard markings:o ATSM F2387 Ct ASME/ANSI Standard A 712.19.17 THI:ABOVE HAS BEEN FIIELD VERIFIED TO CO PLY WITH MANUFACTURES1 MANUFACTURES' INSTAL ON REQUIR121WIEENTS BY THE INSTALLIEER I declare that I hold an active California State Contractor license# with classification Professional Engineer license# or a Caliromia State _with qu2lified experience working on public swimming pools and that the infonnallon 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 Heafth 8 Safety Code Section 116064.2. Convaclor/Erigineer Name: Company Name: o Company Address: p City: i Stale: Zip Code, ,S Contraclor/Engineer Phone Number; Cell Phone Number: Co tor/Englneer F#X Number: Em Can or Engineer name(PRINT) Contra r ngineer name(SIGNATURE Date For a complete text of the law,visit: http llinfas )en.ca gavlpub'09-10/bilUasmf2b 1001-1056lab 1020 biil_200910i1-chaptered.pdf