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ArPROVED FIN <br />DATE: <br />'ICE USE ORLY <br />Fee Feld S <br />FA: <br />INSTALLATION CERTIFICATION <br />VGB DRAIN COVER & SECONDARY DEVICE <br />PR: <br />ump or rrtuitX7mps uniM same cover. SR: <br />, 4-1 Date: <br />NOTE: Use one f,rn for each ,.. 1 <br />For the property named <br />located at 2 i .1 1 v ,etrn, ,,*, _Ynedri-4"0-1,--- , California, I hereby certify that pursuant to Calife,rnia ,..1 i <br />State Health & Safety Code Sec. 114 4.1 and 116064.2, that an Anti-entrapment cover meeting the current standards of the American <br />Society of Mechanical Engineers ASME/ANSI standard A 112.19.8-2007 and where required, a secondary safety device meeting the current <br />ASMEIANSI or ASTM standards will be installed per the manufacturer's instructions on the: <br />0 Swimming Pool0-_:,Z o Spa Recirculation <br />. L 5- f4 Is< Spa Jet 1 Booster 0 Vire.ding/toddier pool <br />.-, Existing PuEnp(s): Make/Model e a I-I.P c-• ; Flow (ppm) / 3 <br />Make/Model 0.1"1- /1.1--' 1-1,P ; Flow (gpm) <br />Main Drain(s): <br />Manufacturer of approved cover. <br /> <br />zeLe41-ie-c/ <br /> <br />Model/Part Number. 41-0,--e; GPM rating: Floor Wail installed on 0 Wall loor <br />Cover bears the following markings: <br /> <br />"VGB 2008 or later", _ <br />"ASME/ANSI standard A 112.19.8-2007 or later", 'Life": ,D <br /> <br />Main drain/Jet suction pipe size is inches. Manufacturer's main drain(s) sump depth requirement in inches is: <br />0 Single drain - Not unblockable (one of the following secondary devices required: SVRS / Suction limiting vent / gravity drainage / <br />auto pump shut-off/ other approved by enforcement agency) <br />Type of secondary device installed: <br />Manufacturer of approved device: Model/Part Number. <br />SVRS bears the following markings: <br />`ATSM F2387", <br />"ASME/ANSI standard A 112.19.17", <br />NOTE: If Installing a variable speed SVRS pump a REntraime Data sheet shall be faxed to EMD at &T-8i3 following <br />the installation. (A sample form is available from the Environmental Health Plan Review office) <br />I:L....Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) <br />Dual main drain(s) <br />Equaiizer <br />Manufacturer of approved cover. <br /> <br />Model/Part Number: GPM rating: Floor ; Well Installed on 0 Wall 0 Floor <br />"VGB 2008 or later", <br />"ASME/ANSI standard A 112.19.8-2007 or later", "Life": <br />Skimmer equalizer line(s) pipe size were found to be inches of Skimmers: <br /> <br />Manufacturer's skimmer equalizer line(s) sump depth requirement in inches is: <br />Single equalizer line <br />Dual Skimmer equalizer line() sump depth inches <br />Skimmers are connected with single line to pump. <br />Skimmers are separately valved before pump and can be isolated. <br />i q 9 ( f'" I declare that I hold an active California State Contractor license # • I :'' ,..e or California State Professional Engineer license-, # <br /> , with qualified experience working on public swimming pools and that the information provided above is true to the best <br />of my knowledge. I'm aware that improper certification of the above information shall be subject to potential disciplinary action at the <br />Iscretion2fyie licensing authority. <br />, 11 c--6 7-6;;;-,::. <br />a kl'r -t.T.1i-e. ' ,--/-"9 Print name ( <br />:fT <br />Cn tact Ra <br /> <br />; ,-- - ,'''' <br /> <br />' L - <br />Phone (7/6; '17 V- 7?--6.'d <br />, ,..„..... <br />• i....F,.-`),„, , ,..„....., . <br />. / <br />cmie: <41 10(41(.1&" / Lai: (.."."-LC,' i - , email itt fli ie.' e 1.61 I <br />PAYMENT DUE PRIOR TO APPROVAL CALL PLAN REViEW AT (cA 8} 57440-10 <br />,11 <br />4 r:ornr:lete trtlA of the law, visit: <br />ilttp:ifinfo.sertca oovipub109-101billiash: L) 1001-1050fab 1020 bill 200910