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APPROVED BY <br />DATE: <br />Spa Recirculation <br />Wading/toddler pool <br />)7/ H.P czQ ; Flow (gpm) / 3 <br />Make/Model itaa..,6 -alli-- /i..44-- H.P ; Flow (gpm) <br />0 Swimming Pool k''y <br />Is< Spa Jet / Booster <br />Existing Pump(s): Make/Mode <br />FiCE USE ONLY <br />Fee Paid $ <br />FA: <br />PR: <br />NOTE: Use one f . fo each • ump or multi um ps und r the same cover. SR: <br />,., , <br />For the property named , / r ,,- - - '6/4,4- Date: <br />located at (...2 1 ill .4( „iv ‘717/4.----04--- . California, I hereby certify that pursuant to California <br />. State Health & Safety Cade Sec. 11 1. .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 />ASME/ANSI or ASTM standards will be installed per the manufacturer's instructions on the: <br />Main Drain(s): <br />Manufacturer of approved cover: <br />Model/Part Number: GPM rating: Floor/22 ; Wail Installed on 0 Wall loor <br />Cover bears the following markings: <br />"VGB 2008 or later", <br />„k" “ASME/ANSI standard A 112.19.8-2007 or later", "Life": <br />Main drain/Jet suction pipe size is inches. Manufacturer's main drain(s) sump depth requirement in inches is: <br />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 />"ASMEJANSI standard A 112.19.17", <br />NOTE: If Installing a variable speed SVRS pump a RPMFrime Data sheet shall be faxed to EMD at 875-8513 following <br />the Installation. (A sample form is available from the Environmental Health Plan Review office) <br />Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) <br />Dual main drain(s) <br />Eaualizer line(s): <br />Manufacturer of approved cover: <br />Model/Part Number: GPM rating: Floor ; Wall Installed on o Wall 0 Floor <br />"VGB 2008 or later", <br />"ASME/ANSI standard A 112.19.8-2007 or later", "Life": <br />INSTALLATION CERTIFICATION <br />VGB DRAIN COVER 8, SECONDARY DEVICE <br />Skimmer equalizer line(s) pipe size were found to be inches # of Skimmers: <br />Manufacturer's skimmer equalizer line(s) sump depth requirement in inches is: <br />Single equalizer line <br />Dual Skimmer equalizer line(s) sump depth inches <br />Skimmers are connected with single line to pump. <br />Skimmers are separately valved before pump and can be isolated. <br />,64" I declare that I hold an active California State Contractor license #41 (4' or California State Professional Engineer license 4 <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 sublect to potential disciplinary action at the <br />iscretion?f e licensing authority. <br />Signature Print name , Date <br />C "4 <br />Contact Name: 11 <br />7 <br />/61 -- Phone ?/'6 Wc) email Avrieererevi c4tif <br />4 <br />PAYMENT DUE PRIOR TO APPROVAL CALL PLAN REVIEW AT (918) 874-8010 <br />For a complete text of the law, visit: <br />DSC ': http://info.sen.ca.qov/pub/09-10/bill/asm/ab 1001-1050/ab 1020 bill 20091011 sj t4I4J f