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APPROVED BY: ifornia Department of Public Healtl 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 DATE: 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. State: Zip Code: Site Information Owners Address 9,c 60.x. is-3 ,,;)„, city Owner Name: -"A-'1" Alt-4(... S Ak v 0 St r 1- 61 Owner's Phone Number: Facility Address: Q26.a. C-7\ywu.c..-o,d, Ave. 63 City: S.-1u C.-,, i-cArsi St: Ce"...Zip: 01 Tao Facility Name: EI1T'l U./ (..,3ci (,.1- ii^r &4‘.) 1/-1_4)4- Pool Identification (if more than 1 pool/spa at site): St aN.. Zip 9 5-1X4C3 Pool constructed on or after January 1, 2010?: ff.) Yes o Jet / Booster Pump H.P •5 . Make/Model H.P Other Pump: Pump Information 0. Recirculation Pump Al Make/Model kklk Feature Pump Make/Model H.P Make/Model H.P Main Drain (Includes All Suction Outlets Except Skimmer Equalizer Line-sl Manufacturer of approved drain cover: Phl f/ A CIA kZ_ Model Number: .....2..cr)F L., Install date 100 7 GPM rating: Floor --3/ .6 Wall Og Installed on *Floor I, Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is _2 inches. Check One: 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) L) 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: safely vacuum release system, suction limiting vent system, gravity drainage system, auto pump shutiiasystem, or other equally or more effective system approved by enforcement agency) Type of secondary device installed: LiAci F ‘,z-c Install date .2..(10 7 Manufacturer of approved device: l'A C il' Model/Part Number: - ki\ -2000 41— 41-F v 1 N 2 U ar2_ (-':,,S 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 VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license # 411 (061 with classification B or a California State Professional Engineer license # with qualified experience w rking 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: 1- tl /6{3E/- Company Name: tiro—of:3z 1-4Do (-- Company Address: *MN CD)( 9 sS City: rA A-Nitac Contractor/Engineer Phone Number: Cell Phone Number: 2o c1* 5---""),S"C) Contractor/Engineer FAX Number: Email: 6-Ar 2-44 trA - Contractor / Engineer name (PRINT) Con r / Engineer name ( NATURE) For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab_1001-1050/ab_1020_bil Date 0091011_chaptered.pdf 0