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APPROVED BY: DATE: OFFICE USE ONLY California Department of Public Health Compliance Form Anti-Entrapment Devices and Systems 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 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 Informatio FacilityName: I 1 4--N2) C_Q__Ae____ Pool Identification (if more than 1 pool/spa at site): C-) Facility Address: --1 CI' \ <3U. /A/. c_c__,a_ City: St: Zip: Owner Name: (Pc-W--6 ?ilt --f) t (''-01/1"‘-4°Pti Owner's Phone Number: 3 3,j - \ Li(1 (,--- Owners Address City St. Zip Pool constructed on or after January 1, 2010?- II Yes E No Pump Information CI Recirculation Pump Make/Model LI Other Pump: Make/Model H.P C k A6C? )et, Booster Pump ake/Model Acc-C-Ci—r()LA/5 5 V • 111 Feature Pump Make/Model H.P H.P Main Drain (Includes All Suction Outlet Except Skimmer Equalizer Lines) Manufacturer of approved drain cover: ,.) Ps--- 5'71ere Model Number: r3 L.L.0(---' Linsta II date GPM rating: Floor ..2--, \., Cr' Wall Installed Installed on E Floor c Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on O Floor E Wall Main drain/Jet suction pipe size is / inches. Check One: Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ingle drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) E Si gle 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 bears the following performance standard markings: Li ATSM F2387 E ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: Model Number: Install date GPM rating: GPM rating: Floor Wall Installed on LI Floor u 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 # 11-LA '-f1/4-1 with classification 645"."5 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 116064.2. Company Name: Company Address: I City: State: C'KA- Zip Code: -W Contractor/Engineer Phone Numbe 61 C7(./:C qi{ 2 Cell Phone Number: Contract /Engineer F Number: Email. C3 (PC-lijO (S16 (-5 Cc)i- / Engineer me (PRINT) cf.& / Er1rier-qarr pate For a complete xt of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/as /ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf 3-Wiz Contractor/Engineer Name: c, Revised: July 14, 2010