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APPROVED BY: California Department of Public Heai.i OFFICE USE ONLY Compliance Form DATE: Anti-Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 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: 1111 / 49 350 Pool Identification (if more than 1 pool/spa at site): Facility Address: &.15 Ira!,1c1 Carne '7ue4Rl k{ ,�—)W City: SfOCk-tyrl St: Zip: 95� Owner Name: 4 4&D/-_ /,' / Owner's Phone Number:ch) Owners Address Z1,05- �/eII G Il1d Kfil,Di ,roe City )fdGk7 ) St.<_Zip 1 sa CSS Pool constructed on or after January 1, 2010?: ❑ Yes b..No Pump Information X RecirculationyP�MP v 1 LlJet/Booster Pump Make/Model 174-W, �41G�-�a55 H.P Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain Includes All Suction Outlets Exce t Skimmer E ualizer Lines) -�` Manufacturer of approved drain cover: Pu) G� e� 1,,://,0 Di(5 Model Number:✓J 36 4) Install date d' GPM rating: Floor/J.3 Wall /a Installed on X Floor ❑ Wall Q / Manufacturer of approvgd�rain cover:_ Ka tet Model Number: Cil/l� d 61 Install date -6 _ao l v GPM rating: Floor �J Wall Installed on ❑Floor KWall Main drain/Jet suction pipe size is off. inches. Check One: ❑ Split main drain(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) 14 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 a,4eency) Type of secondary device installed: V2 `J Install date .3' 36l v f r p o evice: !k Model/Part Number: -5/Z - $_00 r by rs the following pe ormance standard markings:K ATSM F2387 q�SME/ANSI standard A 112.19.17 D VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I Yagretthol an active a i ornia State Contractor license# with classification C S 3 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 California Health& Safety Code Section /116064.2. Contractor/Engineer Name: Zk l-,) — i�e►1 t0Z Company Name: A)4) 4DM' t Company Address: 5-&&q S11 e`! q O f C City: V 4n -3-0!5 State: /q Z 3 Ziip Code: �1�" Contractor/Engineer Phone Number:_I1&9 - e-141p r 7&4, Cell Phone Number: yDrJ - dyj - 1.37 a' Contractor/Engineer FAX Number: !V� - l q('D (0 EmA AY k1D (-,66/em obis•LD.�I Lu. � JIm ehez- `g- 7- 1611] Contractor/Engineer name(PRINT) Contractor/ ngirwzr name(SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab_1001-1050/ab_1020-bill_20091011_chaptered.pdf