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Iu- Irnal aan dbaquln i,ounty No. 0652 P. 2 <br /> =BY: alifornia Department of Public Heal_Compliance ForrnDFFIGE.us oRLr <br /> Anti-Entrapment Devices and Systems <br /> for Public Pools.and Spas <br /> Health and Safety Code <br /> Sections 116064.1 and 116064.2 <br /> NOTE: Use one form for each puma or multiple Pumps under the same drain cover.. <br /> ALL SECTIONS OF THIS FORM MUST BE COMPLETED. <br /> This form is to be used'to verify compliance with modifications pursuant to the now Health and Safety Code <br /> sections <br /> 116064.1 and 116064.2. Under Section 116064.2(a)of the Health and Safety Code,effective January_1, 2010;the owner of <br /> a public swimming pool shall file this form within 30 days following the co <br /> entrapment devices or systems in swimming pools, mpletion of construction or installation of anti- <br /> Contact your local Environmental Health Department and Building <br /> Department for any necessary plan approval and permits prior to construction or remodel. <br /> Site Information <br /> Facility Name: r <br /> N Pool identire lion(if mothan 1 pooUspa at sit <br /> Facility Address: �(�' / �� G ,_ <br /> t Cily: a il..77' SCC Zip: !�a- <br /> Owner Name; Owners Phone Number <br /> Owners Address City <br /> Pool constructed on or after January 1.2010?: O Y St.—� <br /> Yes 11-iso' <br /> Pum formation <br /> ec{lMod Pump <br /> MakeJModel 0 Jet/Booster Pump <br /> H.P <br /> Make/Model H P <br /> ❑ Other Pomp: <br /> Make/Model O Feature Pump <br /> H.P Make/Model <br /> Main Drain Includes All Suction Outle EXce Skimmer E ualizer Lines /p H P <br /> GPM <br /> Manufacturer to approved drain Cover Model Number.,, d-. / _ Q <br /> GPM rating:Floor 3/�O wan Install date"fir' <br /> Installed on � O Wall <br /> Manufacturer of approved drain cover.,i-� /� _ �.9 -/ <br /> -- Model Number;iv—s Install dale Q <br /> GPM rating: Floor Wall Installed on O Floor O Wall Main drain/Jet suction pipe size is J /_ inches. <br /> Check One: /� <br /> O i main drain(s)(Minimum 3 It between covers,hydraulically balance <br /> d and symmetrically plumbed) <br /> )Ingle drain–Unblockable(size and shape that a human body cannot sufficiently`block to create a suction entrapment) <br /> O Single drain–Not unblockable (one of the rollowing secondary devices required: safely vacuum release system,suction limiting vent <br /> system,gravity drainage system•auto pump shut-offsystem„or other equally or more efieCtive system approved by enforcement agency) <br /> Type of secondary device installed: <br /> Manufacturer of approved device: Install date <br /> Model(Part Number: <br /> Safety vacuum release system bears the following performance standard markings:a ATSM F2387 o ASME/ANSI slandard A 112.19.17 <br /> THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER <br /> I declare that 1 hold an active California State Corinclor license# <br /> Professional Engineer license# L with Classmcation 5- or a California State <br /> with qualified eXperience working on public swimming pools and that the information <br /> .provided above is true to the best of my knowledge. I understand that if I impmper)y CORify alis information,I shall be subject to polential <br /> disciplinary anion at the discrelion of the licensing authority in accordance with California Health 8 Safety Code Section 116064.2 <br /> ConlraClOrlEngineer fwa e: Company Name: °O/f <br /> Company Address. o <br /> City; <br /> Stale: Zip Code. r <br /> Contactor/Engineer Phone Num er, � - � <br /> Cell Phone Number., <br /> Conor/Engineer Number: E <br /> p. <br /> 1 fP m <br /> Contractor/tngineer name(PRINT) Contrac r <br /> er name FSIG—NATURE) Date <br /> For a complete text of the law•visit http:/llnfosen_cagovlpub/09-10/bilVwnVab 1001 1050/ab 1020 bill 20091011 chaptered.pdf <br /> 00 NOt 01 X <br />