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H.P H P 02- Jet! Booster Pump Make/Model Pump Information Recirculationflnp,_ Make/Model "Ve rt7 41 r /71Tei 110 0 Other Pump: o Feature Pump Make/Model H.P Make/Model Main Drain (Includes All Suction Outlets Except Skimmer E9ualizer Lines) Manufacturer of approved drain cover: /VOW ILJAVer 5 4 litY, a 4 Model Number: Z2-5 36 0 Install date * 'X)/ 0 GPM rating: Floor /33 Wall /. 3 Installed on X Floor o Wall Manufacturer of approved drain cover: 4 2 (AA. 57-4.,e— Model Number: e7/1106/ Install date g ,911)/ 0 GPM rating: Floor ge, Wall I' 70 Installed on 0 Floor ZLWall Main drain/Jet suction pipe size is .2. inches. Check One: CI Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) Ai Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent I declare Professio provided a disciplinary Company Address: 506 ,ctle // 6/e... City: Sart Jose. State: - 4 Zip Code: 9 Contractor/Engineer Phone Number: Z-/OB '4/1/e - -764,5— Cell Phone Number: ejoe - ;od-- ii 73- Contractor/Engineer FAX Number: 7'O Email: - 4/613 - oci 0/ Email: /14t5ciiNez E/i0p8) jeinpe56 L 140 „Mil eiii-z_ Contractor / Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf gravity drainage system, auto pump§hut-_aff system, or other equally or more effective system approved by en rcement Agency) f secondary device installed: NS Install dat • alb/ u cturer of approved device: 51/ kk- Model/Part Number: SR - 500 release system bears the following rformance standard markings: ijiLATSM F2387 SME/ANSI standard A 112.19.17 lit HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER an active California State Contractor license 35' with with classification CS 3 or a California State er license # with qualified experience working on public swimming pools and that the information e to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential e discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. Contractor/Entraame: 14i,5 JI 4- Company Name: A>6 Pi -gob/m-1 Foo/ H.P APPROVED BY: alif or ni a Department of Public Compliance Form OFFICE USE ONLY DATE: 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 file this form within 30 days following the completion of construction or installation of anti- entrapment devices or systems in swimming poois. 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: nide/ i/C?"2 Pool Identification (if more than 1 pool/spa at site): Facility Address: etc. Tr4 1 131vci city: c-cLci St: 41_ Zip: '153'3 c.0 Owner Name: Gc.0 Owner's Phone Number: 0-01 - e)34.— '71 'cc) Owners Address 301,0 -1-1--44-ci 13140( City (7 St. CA zip ci 3-7 Pool constructed on or after January 1,2010'?:Yes lc No