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API'. 11. ION JO: 19AM San 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 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 installatron 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 ri'A Ptinfe 011ea Pool Identification (if more than 1 pool/spa at site): Facility Name: A Facility Address: It 1)1/// ..Cfr irtni A city:., 5-;="4474ery st: ,:.--,./.# zip: 9'17,7 / ' Owner Name: Owner's Phone Number: Pool COnstrucled on or after January P. 2010?: 0 Yes el4tro— Pump. Information a-gecIrculatiori.eump Jet / Booster Pump Make/Model 4.0friiebffir/G ris-t_sM r H.P Make/Model H.P 0 Other Pump 0 Feature Pump Make/Model H,P Make/Model Check One; GPM rating: Floor Wall installed on 0 Floor &Wall Main drain/Jet Suction pipe size is inches. Manufacturer of approved drain cover: arepkw7A Model Number: 59X6/9-, Install dale Manufacturer Of approved drain cover: Afrivi-pe-7//4- Model Number , ,71/. 'oer, Install date GPM rating: Floor Wall Installed on itr1i3or 0 Wall Main Drain Includes All Suction Outlets Except Skimmer Equalizer Linos) . A 0 Soti lit main drain(s) (Minimum 3 IL between coverS, hydraulically balanced and symmetrically plumbed) p , Ingle drain — Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 'Ingle drain — Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, autoxp.shy(ioq-.1.ystem, or other equally or more effective system approved by enforcement agency) Type of secondary device installed: -71,- 7/.", / /e9 i/fize J 4,"4 f Install date Manufacturer of approved device: Model/Pad Number: Safety vacuum release system bears the following perlorrnance standard markings:0 ATSM F2387 0 ASMEJANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TO CompLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER I declare that I hold an active CalifOmia State Contractor license tt C.-:3 g//.57 . with classification Or a California Slate Professional Engineer license # with qualed experience working on public swimming pools and that the information . provided above is true to the best of my knowledge. I understand that ill 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: Company Name: Company Address: City: Stale: Zip Code: Contractor/Engineer Phone Number Cell Phone Number: Contractor/Engineer FAX Number: Email: Owners Address City St. Zip Contractor / Engineer name (PRINT) Contractor / Engineer name (SIGNATURE For a complete text of (he law, visit: http://info.sen.ca.govipub/09-10/bill/asm/ab_1001-1050/ab_1020_ 91011Lc ; of+ • qtrred.pdf.