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08/17/2012 11:02 2095376599 CUSTOM POOLS PAGE 03/03 Ifornia Department of Public Health Compliance Form Anti-Entrapment Devices and Systems for Public Poole and Spas Ar PROVED BY: e • DATE: OFFICE USLONLY Health and Safety Coda Sections 118064.1 and 116084.2 NOTE: Use one form for each PUMg or mult1018 mime under the tame drain Cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. Thle form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code portions 110004.1 and 118064.2. 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 aystems In awimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site informattOn Facility Name; 0114e- favi< Pool Identification (if more than 1 pool/spa at site): e06 / Facility Address: lie Npv-A-4,4750-k-• City: Mikeihtc... St cA, zo: it5-63Ce Owner Name: Owner's Phone Number Owners Address City St. ____Zip Pool constructed on or alter January 1,20101': CI Yes .1;i4o ' °relation p'Reclreulatlon Purrip_. , 0 Jet! Booster Pump Make/Model •STA.14131,--1- H.P Make/Model H.P 0 Other Pump: 0 Feature Pump Make/Model H.P Make/Model Hr.P pain Drain (Includes All Suction Outletit gffcept Skimmer Equalizer Lineal ianufacturer of approved drain cover A 4X/4 S1(2.#. Model Number: 3aCO 'LP. I1 install date B11 111 ;PM rating: Floor 311, Wall Installed on efloor o Well tlanufacturer of approved drain cover Model Number: Install date ;PM rating: Floor Well Installed on CI Floor 0 Wall Main drain/Jet suction pipe size is inches, ;heck One: Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) KSingle 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: Install date Manufacturer of approved device: Model/Part Number: Safety vacuum release system beers the following performance standard markings: 0 ATSM F2387-ME/ANSI standard A 112.19,17 Skimmer Eggallzer Manufacturer of approved suction fitting: A POI Model Number:Af 'Rio I Install date 8 /1 /1/ GPM rating' GPM rating: Floor Wall installed on o Floor geWell Skimmer equalizer line(s) pipe size were found to be 1/)- Inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH rie,NUFACTURER'S INSTALLATION_REQUIRENIENTS EIV THE INSTALLER I declare that I hold an active California State Contractor license # Pilo/24, 7 with classification 3 -$-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 116004.2. Contractor/Engineer Name: Company Name: A10 " OC44PA" A, e; Company Address; ...5-"?0(2, f4lk 6.0e.c. get City. 022-124 State: Zip Code: 9,53o7 Contractor/Engineer Phone Number g-g? (05-0° Cell Phone Number Contractor/Engineer FAX Number: .5-kfatei M ail: ACINatto 8 11-7 1 i1- Contractor / Engineer name (PRINT) ntractor / Engineer name (SIGNATURE) Date For a complete text of the law, visit: http://Info.sen.ca.govipub/09-10/b111/asm/ab_1001-1060fab_1020_b111_20091011_chapterod.pdf Revised: sivry 14, 2010 Received Time Aug. 17. 2012 11:00AM o. 0893