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APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form FA: Anti -Entrapment Devices and Systems PR: DATE: for Public Pools and Spas 6R: Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each pump or multiple oumps 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. Facility Name: _ Facility Address: Owner Name: (if more than 1 pool/spa at site): Owner's Phone Number: Owners Address City Sl. _ Zip Pool constructed on or after January 1, 2010?: o Yes o No Pumo Information Elk Recirculation Pumf I_ PO Pump Make/Model g''�iYIAVe-111H.�_ Make/Model H P 0 Other Pump: o Feature Pump Make/Model H.P Make/Model H.P Manufacturer of approved drain cover: ^yo V 1' a Inc c' � odel Numbe U19 AIV - Install date GPM rating: Floor ! (G Waller filo Installed on 3YFloor o Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on o Floor O Wall Main drain/Jet suction pipe size is �=hes;. Check One: o Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) o Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) o 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: Install'date Manufacturer of approved device: Model/Part Number. Safety vacuum release system bears the following performance standard markings: 0 ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer Equalizer Linefal E Manufacturer of approved suction Izerc, im JVbfxL1a4 hub 11 Model Number: Install date GPM rating: GPM rating: Floor Wall Installed on []Floor o Wall Skimmer equalizer fine(s) pipe size were found to be inches Number of Skimmers: HE ABOVE HASBEEN FIELD VERIFIED TO C PL W T ANU TINSTALLATIONREQUIREMENTSINSTALLER I declare that I hold an active California State Contractor license # 8 1'4 with classification 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 discipiinyry action at the discretion of the licensing authority inaccordancewith California Health 8 Safety Code Section 111'6064.2. Contractor/Engineer/ Na��me//:I�I/kL��d- 100-Mn.y.eZ&,f7YijSCompanyName:'AZjtrAI1U t 1-6� C bxfi ) S Company Address: l0 1 Y 1141 rGleI () lei City: t--t)umIz, Contractor/Engineer Phone Number: '5 i) %r7 Contractor/Engineer FAX Numb c G% / to - -7 CJS /1 d 1166A o , r/ r C rTtrador % Engine r name (PRINT) For a complete text of the law, visit: http://lnfo.sen.ca State: C/F Zip Code: , Cell Phone Number: ql&- u9 G_ -W name (SIGNATURE) Date 01.1060/ab 1020_blli 20061011 chaptered.pdf Reond My 14,2G)V