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APPROVED BY: DATE: OFFICE USE ONLY California 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 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 fife 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 InformationAA Facility Name: fade/ & . 1°1330 Poe! friantifientinn (if more than 1 pool/pa atsite): Facility Address: * "7 Ala v .7' Dr-. City. liot440/ - . (/I Zip. T 5 Ca , Owner Name: //o r , Owner's Phone Number. T=369 - 6/4/6 - O3 3 Owners Address e17 iukvi y Or City ,YD(.- /-40rI St lt Zip Pool constructed on or after January' 1, 20107: 0 Yes 4. No Pump Information 0 Recirculation Puilrip , -_, A441465 if H.P / //01._ 0 Jet I Booster Pump Make/Model :57 ,4,- Make/Model H.P O Other Pump: 0 Feature Pump Make/Model H.P Make/Model H.P Main Drain (Includes All Suction Outlets Except Skier Equalizer Lines) Manufacturer of approved drain cover: 1t2 iticcik" e Model Number: p Via.: 5 30) install date •:)76/27 GPM rating: Floor 03 Wall /I-3 Installed on A,.Floor 0 Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on 0 Floor 0 Wall Main drain/Jet suction pipe size is inches. Check One: o Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) 0 Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) tic!, Single drain - Not linhinrkahlo (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity dr system, auto pump shut-off system, or other equally or more effective system approved by enforcernentagericy) Type of second . installed: 3V e_s Install date --gt Manufacturer o - device: P.3/ Model/Part Number: 45 0-50 Safety vacuum rele bears the following performance standard markings: 0 ATSM F2337 ASME/ANS1 standard A 112.19.17 Skimmer Equaliz Manufacturer of GPM rating: G Skimmer eg tion fitting: )74.-c) 4..1- Modef Number: SR— Reif () Install date loor %),c)c) Wail /q Installed on 13 Floor Wail ) pipe size were found to be I inches Number of Skimmers: THE k3/4 AS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION FrEgu;r-m-m;_---...NTs BY THE INSTALLER i declare that I hoi an active California State Contractor license # 570 35 with C 5 3 of a Califoinia Stz-Jie Frotessional Engineer license # with quaiified experience worKing on public swimming pools ano 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. I 14 5 Company Name: Company Addie 9,409 54t $e City: cSart ads e State. 611 Zip Code: 951?-3 Contractor/Engineer Phone Number: q06? r.rst! Phone Number' 110E3 - 3 7J-- Contractor/Engineer FAX Number. Ot3 Lill - 690/ ite2--16). 400 ri) A leptpa t &Pi Lti. 15 ji 1/KAfte 2_ /0 . 5 01-4.)1 CUriii acith- I Engineer , name (PRANT) Cir,tioctor nerne (SICt-IATLIP.E_) 'For a completi;: tc,xt of the law: http:ilinfo.sen.ca.c.mv!pubt09-101billIas-rniab_1001-10501ab_l 020_bi!!_nngl Al 1 _nhtlr..torf-rif A.)6> -Pi--4>h1e Poe3