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Pool IdentifiCation if more than 1 pool/spa at site: City:, ,..49G St..Z Zip: -.70 ale red.pdf Apr. H. ZHU Ii: 9/M an Joaquin County No. 0652 APPROVED BY: _.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 OFFICE USE ONLY DATE: 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 116054.2 (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 installaton 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: e Facility Address. Owner Name; Owners Address City St, Zip Pool Constructed on or after January 1, 2010?: o Yes iErg; Jet / Booster Pump Make/Model .4,-/7 C H.P 0 Other Pump: Feature Pump Make/Model H,P Make/Model H P Main Drain Includes All Suction Outlets Except Skimmer Equalizer Lines1 GPM rating: Floor Manufacturer of approved drain cover. GPM rating: Floor 3 /1 Manufacturer Of approved drain cov er: )."..Arr- Wall 2e ,r Installed on dr<oor 0 Wall Model Number 3..?672./-=-z Install date Model Number: Install dale) -----:/Z7 './) Check One; Installed on o Floor 0 Wall Main drain/Jet suction pipe size is inches. 0 Split main drain(s) (Minimum 3 It. between covers. hydraulically balanced and symmetrically plumbed) 4--Slile drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 0 Single 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: o ATSM F2387 0 ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN F1E1,0 VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license tie: (2S', / a 57 with classification Or a California State Professional Engineer license # with qualified experience working on public swimming pools and lhat 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 licensingauthority in accordance with California Health 8, Safety Code Section 116064.2. Con LraCtOdErigineer Name: Pk / 1-/t 4 /.0(c- Company Addres City: Stale: X, _ Zip Code: fie vr/Engineer FAX Number: (0,71 3 3 '163 .2%.1 ontraclor / Engineer name (PRINT) Contractor,' Engineer name IS For a complete text of the law, visit: http://Info.sen.ca.gov/pub/09-10/bill/asm/ab_1001-101 0 gi Owner's Phone Number: Purap_tnformalion LE'Recircula lio ump Make/Model fel /-2;11' Company Name: Name: ,,QTrair2? Ao7; Contractor/Engineer Phone Number. Cell Phone Number: Email: /c.,ei?/ eq`