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APPROVED BY: DATE: OFFICE USE ONLY Contractor/E gineer Phone Number: Contract eer FAX Number: - / er name (PRINT) , Contract of/ Eng neer name (S‘NATURE) Dat visit: http://Info.sen.ca.gbv/pub/09-10/bill/asm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf Revised: July 14. 2010 C. For For a comple Company Name: Zip Code: _ ) , Cell Phone Number: Email: Contractor/Engineer Name: Company Addres): City: 0 State: 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 pum_p 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 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 Information Facility Name: 7 r=w a Facility Address: Address: /PO 7:;/-n c, 94C/ Owner Name: Pool Identification .(if more than 1 pool/spa at site): City: e1<ei St:44 Zip: ci'..5:7;7i•4 Owner's Phone Number: Owners Address Pool constructed on or after January 1, 2010?. City St. Zip 0 Yes u--4117 Pump Information Jet / Booster Pump 1rRecirculationpump /. u Make/Model rtifiii -47/ e'2 H.P L/5 Make/Model H.P H.P El Other Pump: Feature Pump Make/Model H.P Make/Model Main Drain (Includes All Suction Outle) Except Skimmer Equalizer Lines). . Manufacturer of appr ved drain cover: /-2,,rqin,;,z,,,3 f--- Model Number: ,. / GPM rating: Floor 4'7 Wall Installed on ierfoor IA Wall Manufacturer of approved drain cover: Model Number: \ Install date GPM rating: Floor Check One: D Split main drain(s) (Minimum 3 ft, between covers, hydraulically balanced and symmetrically plumbed) D Single drain — Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 171 Single drain — Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent ' e, / 6: system, gravity drainage system, auto_pumpihuy7syt /" Inst all date 3 eryi, or other equally or more effective system approved by enforcergent agency) Type of secondary device installed: Zf -7 Manufacturer of approved device:,-/7/-ai .'7-- Model/Part Number: Safety vacuum release system bears the following performance standard markings: 0 ATSM F2387 0 ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: Model Number: Install date GPM rating: GPM rating: Floor all Installed on 0 Floor o Wall Skimmer equalizer line(s) pipe size were found to be inches Number of Skimmers: Install date 3D-9 -/7 Wall Installed on o Floor 0 Wall Main drain/Jet suction pipe size is inches. 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 # X/,‘1,12-7 with classification *"..S".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 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 Healt & Safety Code Section 116064.2.