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Stale: Cell Phone Number: ail: City: Contractor/Engineer Phone Number. Contratr ngineer FAX Number: • fl)i. LI. LU1 1.1 Hi: I YMIVI oan Joaquin (Aunty No. 0652 P 2 APPROVED BY: .lifornia Department of Public Health OFFICE USE ONLY 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. Site Information Facility Name: Department for any necessary plan approval and permits prior to construction or remodel. entrapment devices or systems in svvirnming pools. Contact your local Environmental Health Department and Building a public swimming pool shall file this form within 30 days following the completion of construction or installation of anti- 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 4/9f i-h Facility Address: Owner Name: Owners Address City St. Zip Pool Constructed on or after January 1.2010?: 0 Yes ek1To--- H.P H.P ualizer Lines 6, - rart4424nt- Single drain - Unblockable (size and shape that a human bogy cannot sufficiently block to create a suction entrapment) 0 Single drain - Not unblockable (one of the following secondary devices required: safely 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 F2387 0 ASME/ANSI standard A 112.19.17 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 1/1.) -)a/tC"/„)---/ with classification (.5 3 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 III improperly certify this inforrnation, 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:// -',V7i:(2--/ DATE: Pool Identification (if more than 1 pool/spa at sit ). City: St; Owner's Phone Number. RAJ( Pump Information Recirculation P Make/Model Other Pump: Make/Model Jet!O Booster Pump Make/Model o Feature Pump Make/Model H P Main Drain Includes All Suction Outlet Exces Skimmer E Manufacturer of approved drain cover GPM rating: Floor 1610 91" Wall Manufacturer of approved drain cover: GPM rating: Floor 2e2rf.) Wall Check One: Installed on o Floor fa-Vtar Main drain/Jet suction pipe size is inches. Split main drain(s) (Minimum 3 ft_ between covers. hydraulically balanced and symmetrically plumbed) Model Number., j-19A 4c1fre Install date fil's) Installed on ta-FiCior 0 Wall Model Number:TY-5>i9 Install dale Contractor/Engineer Name: Company Address- P9/ idt,X 7/.? Zip Code: 2.572. Co Ira or / Engineer name (PRINT) Contractor / En neer name (SIGNATURE) ale For a complete text of the law, visit: http://Info.sen.ca.gov/pub/09-10 /bill/asm/ab_1001-1050/ab_1020_bill_ 0910ti• cba'pter414c49 „