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APPROVED BY: California Department of Public Health Compliance Form OFFICE USE ONLY FA: 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 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: 514/v0 (12( 4f7s Pool Identification (if more than 1 pool/spa at site): Facility Address: / 7()1 5 49/1/5' 4.L/1( City: 4_ o St:( Zip: 95z L Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1,2010?: LI Yes A No Pump Information E1 Recirculation Pump g Jet! Booster Pump Make/Model - H.P Make/Model /-/ArZA.IX,e/.) 'F)--5D H.P . 0 Other Pump: 0 Feature Pump Make/Model H.P Make/Model H P Main Drain (Includes All Suction Outlets Ex ept Skimmer Equalizer Lines) Manufacturer of approved drain cover v4 5-7-4 /e-- Model Number 3 Install date .5./Ze) GPM rating: Floor -13 Wall Installed on A Floor LJ Wall Manufacturer of approved drain cover Model Number Install date GPM rating: Floor Wall Installed on El Floor D Wall Main drain/Jet suction pipe size is 7 inches. Check One: A Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) IT Single drain — Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) D 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: El ATSM F2387 u ASMEJANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: N/A (autofill) Model Number: Install date GPM rating: GPM rating: Floor Wall Installed on El Floor D 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 # 701670 with dassific,ation c-63 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. Contractor/Engineer Name: Joe Pagluica Company Name: Pool Time Company Address: 11363 Pyrites Way City: Gold River State: CA Zip Code: 95670 Contractor/Engineer Phone Number 916-638-7665 \. Cell Phone Number \-- Contractor/Engineer FAX Number all: p ' 6,- --5 r' /z-0 ......--( Contractor / Engineer name (PRINT) C tractEngineer name (SIGNATURE) Date For a complete text of the law, visit httplfinfo.sen.ca.gov/pub/09-101billia Tiab_1001-1050Iab_1020_bill_20091011_chaptered.pdf PR. SR: Roved: July 14 2010