COMPLIANCE INFO_2022 - Laserfiche WebLink

Home Browse Search

APPROVED By-. California Department of Public Health OFFICE USE ONLY Compliance Form AnVI-Entrapment Devices and Systems i. DATE: for Public Pools and Spas .Health and Safety Code Sections IiG064.1 and 4H6064.2 NOTE:Use one form for each pump or multiple Qumps under the same drain coven ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compliantg with modifications pursuant to the new Health and Safety Code sections 116064.1 and 116064.2. Under Section 116084.2(a) of the Health and Safety Code, effective January 1, 2010, the owner of a public swir ming pool shall file this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems fr. 61mimming Pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and Permits.prior to construction or remodel. "'ein'orrnatl on�f aci ity Name: Pool Identification(if more than 1 pooil-qpa at zii-,1- Facility Address: CeL ✓ —city: Si:�Zip: Owner Name: V Owner's Phone Number: Oivners Address City Zip Pool constructed on or after January 1,2010?: 0 Yes hump Information 0jet I roaster Pump Make/Model Make/fOodel H.P LJ Other Pump: o Feature pump -MakeliViodel MakelModel H.P Bastion Outlets Except Skim _rEagutilizer Linsel Manufacturer Of approved drain cover. I '%- - Model Number. Inst-tall date GPfA rating:Floor Wall— Installed on ri Floor :i kAjap IV12nufacturer of approved drain cover Model Number: Install date GPIW rating: Floor W211 Installed on 0 Floor o Wall Main drain/Jet suction pipe size is_a— �incches. tPlit Main drain(s)(Minimum 3 ft.beivueen covers, hydraulically balanced and symmetricailly plumbed) Single drain—Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment') 4:3ingle drain—Not unblockable (o,-Ie of the Tolloyfing secondary devices required: safety vacuum release system,suction limiting vent system,gravity drainage system, auto pump shut-offj system,or other equally or more effective system approved by enforce mient agency) Type of secondary device installed.- Install date Manufacturer of approved device7- Model/Part-Number: Safety vacuum release system bears the fallowing performance standard markings:Ei ATSM F23877 0 ASME/ANSI standard A 112,19.17 Skimmer E ualizer Lin-!- Manufacturer of apprmied suction fitting- Model Number. Install date G GPIVI rating:GPWI rating:Floor- wall— Installed on -.Floor o Wall Skimmer equalizer line(s)pipe size were found to be __--inches Number of Skimmers: '171-1 �OEQ TO COMPLY IF41TH MANUFA TUjER!S WSTALLATION REQUIREMENTS'BY THE INSTALLEER I declare that I hold an active California State Contractor license�_Ie?l F 4,46--vAth classification G S or a California State Professional Engineer license# with qualified experience viorking on public svdmming pools and that the information provided above is true to the best of,my kmokuledge. I understand that if improperly certiFyffiis information, I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance vAih California Health&Safety Code Section 116064.2. Contractor/Engineer Name: Company Name: Company Address: _7 11, State: 1 Zip Code. Vontra(:;torlEngineer Phone Number: 7 0 Call Phone Number: Contractor/Engineer FAY,Number. Z116 Contractor!Engineer naML R(SIGNATURE) Date N,T) Contra-&I Engineer (Pf?I 12&Or I Engin POr a Complete ,text of the law,visit: http:11iri u109- 0b i I go.sen.ca.govlp bililasm/ab— ;r-1 050/ab102Q_bilL2009i 01 1—chaptered.pdf Revised:idy 14.2010