COMPLIANCE INFO_PRE-2020 - Laserfiche WebLink

Home Browse Search

APPROVED BY: DATE: Zalifornia Department of Public Heal. Compliance Form • 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. oFFICE.USE ONLY 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 #3W577 with classification(' 5-3 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 8 Safety Code Section 116064.2. Split main drain(s) (Minimum 3 It. 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) 0 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: me: Contractor/Engineer N Company Address: City: Contractor/Engineer Phone Number. 33 'V 71,2 Company Name: 4?4/ 7/1 Stale: Cell Phone Number: 8004' Zip Code: /15,233 Apr. //. 11)IU 10: 19AM San Joaquin County No. 0652 This form is to be used to verify compliance With Modifications pursuant to the new Health and Safety Cod-0 section's - 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 instailatton 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: a ,4 Facility Address: _2 og zZ/ Owner Name: Owners Address City _____Si. Zip Pool constructed on or after January 1, 2010?: 0 Yes Pool Identification (if more than 1 pool/spa at site): City: gdre St: ei41 Zip: ciy,:ze Owner's Phone Number. Jet / Booster Pump Make/Model H.P Feature Pump Make/Model H.P P urspAnformali on w -Recirculation P Make/Model F46 H.P 0 Other Pump: Make/Model H.P Main Drain (Includes All Suction Outl ts Manufacturer Of approved drain cover. GPM rating: Floor 73[4 Wal Manufacturer of approved drain cover: GPM rating: Floor Wall Check One: Except Skimmer Equalizer Lines) t/611- Model Number 3:2(ft Install date 6 -/47 Installed on tirFlTer 0 Wall Model Number: Install dale Installed on o Floor 0 Wall Main drain/Jet suction pipe size is inches. Con1raip nginear F N ber: Contor! Engineer name (PRINT) Contract ngineer 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_c aptered.pdf