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.,.,•,r. cu Iv I'J.17nnl odn Joaquin 6oun(y No. 0651 P. 2 LAROVED BY: :alifornia Department of Public Heal . COmpliance Form OFFICE.USEONLY E: 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 Code sections 116064.1 and 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January.l, 2010; the owner of a public swimming pool shall file this form within 30 days following the completion of construction or instaifalion 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. Site Information •L J Facility Name:.0 9 >�ldwf Pool Identifi@anon f more than 1 pool/spa at site): �, Facility Address: ��,n�i� w-�Gu ��/ -city- Loi. sI: zip: c2 ..-a-y Owner Name; � p: r �y-? L Owners Address Owner's Phone Number. Pool Constructed on or after January1. 20107: O yps V r �_ Pumn lion C�'Raclrculati�u Make/Model ❑ Olher Pump: Make/Model u o ❑ Jet/ Booster Pump Make/Model _ O Feature Pump MakeJMm m —7iP inuui uram Includes All Suction Dull FJtce Skimmer E uahzer Lines ~ Manufacturer of approved drain cover. e!' EEZ&GPM rating: Floor L` /- wall Model Number. Install dale Installed on t f O Wall Manufacturer of approved drain cover: �- GPM rating: Floor. W If r Model Number: i �InStall date /�f a Installed on C Floor tlraiNJet SUCliOn T-` Check One: pipe size is f:� inches. O splil main drain(s) (Minimum 3 IC between covers, hydraulically balanced and symmetrically plumbed) O Sin ain - Unblockable (size and Shape that a human body cannot sufficiently block to create a suction entrapment) Ingle drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage System, auto m p p 5hu1-oH Sy tem„ or dlber guatl r more ettective system a Type a secondary device devicled��P�� 7 _%pj Y approved by enfo em nt agency) Manufacturer of approved device: �c Install dal /f Safely vacuum release system bears the followinModel/Part Number: g performance standard markings: o ATSM F2387 ❑ ASME/ANSI Standard A 112-19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER 1 declare that I hold an active California State Contractor license q , Professional Engineer license #��' with classification G i..J' or a California Slate with qualified experience working on public swimmin Provided above is true to the best of my knowledge. I understand that if I im ro 9 pools add that the information disciplinary action at the discretion of the liicensin aulhon p PAY certify this information, I shall be subject to Potential yin accortlance wish California Health 8 Safety Code Section 11Fnen � Conuaclor/Engineer Com City: Conn Con for/Engineer F `( Number: l , 11kl� Contractor/ Engineer name (PRINT) For a complete text of the law, visit: htto_ulnf„ Cell Phone Number: eer name (SIGNATURE) pale _1001-1050/ab-1020_bill_20091011 _cha ptered. p df vU4NI (A ell