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APPROVED BY: DATE: i,autornta ueparrmenr or ruonc mealm 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 Dump 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: L iC-e C.� ��C 2mcu �L-�a'" l<LJ�_� y%S Pool Identification (f more than 1 pooUspa at site): Facility Address:/r// _4.',,, y lLs�// city:)=':2oi/ Sb r'4 zip: is's�Y�2 Owner Name: Owner's Phone Number. Owners Address City St. _Zip Pool constructed on or after January 1, 2010?: ❑ Yes 4/ No Pum drmation"7A- Recirculation Pump // / ❑ Jet / Booster Pump Make/Model ./Gd- H.P� Make/Model H_P ❑ Other Pump: O Feature Pump Make/Model H.P Make/Model H P Manufacturer of approvedgqd��rain cover: GPM rating: Floor Pr/ O V Manufacturer of approved drain cover 7"- Mode umber. 5',-%?e.%ycn Install date Installed on ❑ Wall Model Number. Install date GPM rating: Floor Wall Installed on 0 Floor ❑ Wail Main drairUJet suction pipe size is inches. Check On Split main dram(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ❑ 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 agency) Type of secondary device installed: S)/ ✓2 S' Install date Manufacturer of approved device: Pfi 2a%z_ Model/Part Number. Sr - 5-0 A Safety vacuum release system bears the following performance standard markings: ❑ ATSM F2387 0 ASME/ANSI standard A 112.19.17 I declare that I hold an active California State Contractor license # tel' ��y'a'/ E with classification C'_ 4 / or a 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 Califomia Health & Safety Code Section 116064.2. Contractor/Engineer Name:-�3'.//ylvir� �YJ2e-��v Company Name: Company Address: City: Contractor/Engineer Phone Number. Contractor/Engineer FAX Number: Contractor) Fora complete text State: Cell Phone Number: Email: Code: Contractor / Engineer name (SIGNATURE) Dale v/pub/0940/bill/asm/ab_1001-1050/ab_1020_bill 20091011-chaptered.pdf