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APPROVED BY: DATE: OFFICE USE ONLY Anti-Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one farm 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: ,(ki/(4-difel/ ,Pool idenfification (if more than 1 pool/spa at site): zeee. if. 1 /4 '7C"‘ /).2/7fX- )64 City: I) liz-!-xteiz_.; stz--2# zip: Facility Address: .:_-_-,27`(,Y 77 Owner's Phone Number: City St Zip Pool constructed on or after January 1, 2010?: Yes No California Department of Public Health Compliance Form Owner Name: Owners Address Pi Imp Information Recirculation Pump Make/Model H.P ‘1,o Jet / Booster PV4 71 /1 7/-7 H.P)-- 0 Other Pump: Make/Model H.P Feature Pump (,.1k;e- e:7 Make/Model H.P Main Drain (Includes All Suction Outlets Except Skimmer Eaualizer Lines) Manufacturer of approved drain cover 1-e-see7/---ear Model Numbeil°77-e f install date GPM retina: Floor / X% Wall Installed on loor 0 Wall Manufacturer of approved drain cover Model Number Install date GPM rating: Floor Wall Installed on o Floor 0 Wall Main drain/Jet suction pipe size is inches. Check One: plit 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) Single drain — Not unblockabie (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 bears the following performance standard markings: 0 A.TSM F2387 o ASME/ANSI standard A 112.19.17 Skimmer Ectualizer Line(s) L,yy7 - Manufacturer of approved suction fitting: d2E7te-ze_,<_} Model Number: Install date GPM rating: GPM rating: Floor Wall Skimmer equalizer line(s) pipe size were found to be Installed on o Floor 0 Wall inches Number of Skimmers: 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 # ?../Y with classification 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 ex Safety Code Section 116064.2. Contractor/Engineer Name: Company Name: ii-)6)6L, 5 , z...i)V 4.,./ ,-- Company Address: i 74 eq ,,, 7 I /le/ c--7:e , 7 City: •:-.--Yilr-(. 7`( ,-I 1'7 i- 7,Li 7-7 ---:/rc -5 State: t/-r i Zio Code: ,3417 Contractor/Engineer Phone Number: cl/ 6 — 97 Y — 0 Cell Phone Number: ContractoriEneineel- FAX Number: 9/6 — 65)/- --, . a • ---- i--__. / -7/.c .(::::&.--7-1/ ).- — / i _ •,' ,r---- Contractor I Engineer nanie (PRiNT) - ContractOr I Engineer nirpe (SIG NATURE).t For a complete text of the law, visit: http://info.seroca.govipub/09-101billiasmilabol00f-1050fabett0201:bilrf O'167.11:i4 or-o Revised: Juty 4. 2d-iD JTt t