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/f 1 APPROVED BY: DATE: Caiifor• Department of Public Health 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 PO OT Diss 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 1, 2010, the owner of a public swimming pool shall file this form within 30 days following the completion of construction or installation 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 Facility Name: j[/ ((46+6- 6i 5,J^PW,< C.4vrs Pool Identification (if more than 1 poolispa at site): / Facility Address: ) City: �y St cA- Zip: $ 376 Owner Name: %6 7 r -a a+.r .��w�v-u7- A (giiexNAT-wa Owner's Phone NumberzL4. Owners Address % 112-0 t 3City I nfi:5i C Std Zip %S3.S� Pool constructed on or after January 1, 20101: o Yes 1V-Nc Puwo Information R Neclrculation Puump i oke/Modet�'nr APA, W #U=)�vc F✓,� H.Pj! 5 o Jet/Booster Pump Make/Model H.P 0 Other Pump: 0 Feature Pump Make/Model H.P MakelModel H.P Manufacturer of approved drain cover: A 1A- Na Model Number. 140 Ad ret Install date GPM rating: Floor .700 Wall Installed on ¢Spoor 0 Wall ,r� � Manufacturer of approved drain cover. 1 Model Number: \O ft �h I Install date�� Ido GPM rating: Floor -2M Wall Installed oneilFloor 0 Wall Main drain/Jet suction pipe size is �inches. Check One: QLSplit main drain(s) (Minimum 3 ft between covers, hydraulically balanced and symmetrically plumbed) 0 Single drain - Unbiockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 0 Single drain - Not unblockable (one ofthe 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 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 ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VER IEDTO COMPLY WIT M U ACTURER'S INSTALLATION E UIRE ENTS BY THE INSTALLE I declare that 1 hold an active California State Contractor license # with classificatio ore 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. 1 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: kheaTn- &4Kc2T Company Name: 61ftjj `T. Ai 4, gASAZrLr, CAI Company Address: 10u)J /J 6jCnhTAC„a Pu City: GT mai State: CA Zip Code Contractor/Engineer Phone Number(ax) 5te/,7-33r 7 C,RII Phone Number: Contractor/Engineer FAX Number. - a77 -r70 Emai', rlm\ Abn�!- 2 aJ Contractor / Engineer name (PRINT) Contractor / Etineer name (S ATURE) D to Fora complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab-1001-1060/ab-1020-bill-20091011_chaptered.pdf