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APPROVED BY: DATE: nIH . L I . ZUlU IV. I an Joaquin (Aunty No. 0652 P. 2 .lifornia 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 mult!ple Dumps 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 shalt file this form within 30 days following the completion of construction Or installatton of anti-entrapment devices or systems in sWirnming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to Construction or remodel. Site Information /al Pool Identification (if more than 1 pool/spa at site): spc. City: ...$7-0,/rfre, St:/ Zip: Owner's Phone Number City Pool constructed on or after January 1, 2010?: o Yes ¢1.-fdr Pump information CI Recirculation Purpp Make/Model )/c H.P 0 Other Pump: Make/Model H,P Main Drain Includes All Suction Outlets Except Skimmer Equalizer Lines Manufacturer of approved drain cover Mad f,e/*/- Manufacturer of approved drain cover: GPM rating: Floor Wall Check One; Company Address: 3/0? Contractor/Engineer Name: 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. Professional Engineer license # with qualified experience working on public swimming pools and that the information I declare that I hold an active California State Contractor license #4.5-3 gy6/5-/- with classification or a California State Safety vacuum release system bears the following performance standard markings: o ATSM F2387 0 ASME/ANSI standard A 11219.17 0 Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 0 Split main drain(s) (Minimum 3 It. between covers, hydraulically balanced and symmetrically plumbed) THE ABOVE HAS BEEN Flt..0 VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER Manufacturer of approved device: Type of secondary device installed: system, gravity drainage system, auto pump Shut-off system, or other equally or more effective system approved by enforcement agency) Company Name: /1;;;//2474 Install date Model/Part Number: OFFICE.USE ONLY Facility Name: Facility Address: Owner Name; Owners Address St, Zip Jet / Booster Pump Make/Model H.P Feature Pump Make/Model HP GPM rating: Flow 3/4' wan 2,er `71,? Model Number 3:4, C-,0/"Z Install dale Installed on Erraor 0 Wall , Model Number:6/66' Installed on o Floor (4407511 Main drain/Jet suction pipe size is Install dale inches. City: i/jen e Contractor/Engineer Phone Number. Contr. eer FAX Nu 'er: Stale: Z7sil Zip Code: Cell Phone Number: ContclOr / Engineer name (PRINT) Contractor/ Engineer name (SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/biWasm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf A v I IV lij'v c,,)1 ukW