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AP PIt: 4 DATE: ralifornia Department of Public Hpalth Compliance Form Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 OFFICE USE ONLY 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 Code section 116064.1 and 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner c a public swimming pool shall file this form within 30 days following the completion of construction or installation of ani entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Buildin Department for any necessary plan approval and permits prior to construction or remodel. Facility Name: 2 VALITy I fufv -Sw f_JF 5 Pool Identification (if more than 1 pool/spa at site): Na Facility Address:_ 1�i$5S S• { tQCzLAN ROAi city: L,riioH1?D? st LA zip: _ �_,_ Owner Name: Owner's Phone Number:_ 01_ Owners Address City SL Zip Pool constructed on or after January 1, 2010?: o Yes ;k No Pump Information ❑ Recirculation pump o Jet / Booster Pump Make/ModelH.P,_)_:__S_ Make/Model E O Other Pump: o Feature Pump Make/Model H.P Make/Model - H.P Manufacturer of approved drain cover. p VASTA [Z Model Number: S AV -Q[ X Install date GPM rating: Floor S 6. RM Wall Installed on rAFloor o Wall Manufacturer of approved drain cover: AAU4STA r2 Model Number: E H F' N12 101 Install date GPM rating: Floor Wall S(o 0.2 M Installed on O Floor ,Wall Main drain/Jet suction pipe size is �_ inches. Check One: )( 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 pump shut-off system, or other equally or more effective system approved by enforcement agent Type of secondary device installed: Install date Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings: o ATSM F2387 o ASME/ANSI standard All 2.19.17 I declare that I hold an active California State Contractor license #L� , (%�� iJ _ with classification ora 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/EngineerName::`N�G)CL rA2C (!A Company Name: N ( GU( -L aoC Cl, Company Address: 1 C) - (�j o j( q 5 City: M fa NT rnQ State: C A Zip Code: Contractor/Engineer Phone Number: O9i G 4 '(p b�2 Cell Phone Number: _20 ! - SI S- aft 0 66 Contractor/Engineer FAX Number: Email: Contractor/ Engineer name (PRINT) Contractor ngineer name(SIGNATURE) T7Date For a complete text of the law, visit: http:l info.sen.ca.gov/pub/09-10/bill/asm/ab-1001-1050/ab-1020_bill-2DO91011_chaptered.pdf