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Company Address: ./ ).7e/ /1 171/71 City: 727E-F-Y7-6 /./ee/1 State: to°/7- Zio Code: eCisd-7-f ,1 APPROVED BY: California Department of Public Health Compliance Form OFFICE USE ONLY Anti-Entrapment Devices and Systems DATE: 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, 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 fife this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems in ewimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information ,.4-,/ Facility Name:li - i4.1,/et/-(1 ddi ool tden5ication (if more than 1 pool/spa at site): Facility Address: 722fri 77 4,2t ii-=.6 42/W-1City: e I , , ee-- /14' 1e..ocle,R....= St: Zip: Zip: 1-57.1 Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 2010?: 0 Yes vg No Pi 70 Infomiation Recirculation P1.43/ H.P 3 e190/1, Make/Model 0 Jet / Booster Pump Make/Model H.P 0 Feature Pump Make/Model H.P Main Drain (Includes All Suction Outlets Except Skimmer Eaualizer Lineal Manufacturer of approved drain cover: ZG-%-e 6a-r_oe Model Number/717. Install date GPM rating: Floor / )L2 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 ATSM F2357 0 ASMEJANSI standard A 112.19.17 0 Other Pump: Make/Model H.P Skimmer Eauelizer Line(s1 \*7'. Manufacturer of approved suction fifting: 27-e (7 • & 7/2 Model Nt:tbera--e-ee--<---) Install date GPM rating: GPM rating: Floor Wall Installed on 0 Floor 0 Wall Skimmer equalizer line(s) pipe size were found to be 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 :4' el 7/,9 (:• with classification e6- 3 or a California State Professional Engineer license ft 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 116064.2. Contractor/Engineer Name: Company Name: Cif „ /66:1f.-) 5 Contractor/Engineer Phone Number: 5.77 — 97 (74' Cell Phone Number: „ Contractor/En r. 7gineer FAX Number. / - ce‘- Contractor de-Freete = /7' L-77h1. e.Freet-'75-f . /ha / / Engineer narrie (PRINT) Contractar I Engineer n -re (SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/05-101billiasmtab_100 -1050/ab_1020_bill 1 124cOle. pkg Tkcia df :tfd, Revi.se: July •i4. 200