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APPROVED BY: DATE: AUG-7:2013 08:04A FROM: T'- '16873277 P. 2/4 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 'Dump 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. OFFICE USE ONLY State: 44 17- Zip Code: 0 Si& 6„ Contractor/Engineer Phone Number: "7_)'( 5 7, l '17 3 -7 —5 Cell umber: $ ketyvLe... Contractor/Engineer FAX Num.1,-) A , co-7 14441-1-e- 2 1 a—el-7*A , Ltyin A-ph (-6-c Ili: IS/ cif 3 Contractor/ Engineer name (PRINT) Con r e (SIGNATURE) Date For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab J001-1050/ab_1020_bill_20091011_chaptered.pdf Site Information Facility Name: .Tifil-cf/ PA, lit- A-05 . Pool Identification (if more than 1 pool/spa at site): Facility Address: 7f7 A/ 7/ A-ci 871 VI) City: A-C-41 St PA-Zip: q s- Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 20107; 0 Yes Ge,St Pump inforrnatlort Recirculation P 0 Jet I Booster Pump Make/Model 414,1 y ww ,pio H.P -1-- Make/Model Other Pump: 0 Feature Pump Make/Model H.P Make/Model H.P H.P Main Drain (includes All Suction Outlets Except Shimmer Eoualizer Lines) r _ q o - 1-5 JO Manufacturer of approved drainover. 5 pro Model Number LP' Install date 7 /6"!7 /6 /4413 GPM rating: Floor ipso 9m a, Installed on gre<or ta4all Wall (tot.? q 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 Onfir '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) Single drain -Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pumpgut-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 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: 5 GPM rating: GPM rating: Floor 100 q7144 Wall (0 It e po„ Skimmer equalizer line(s) pipe size were found to be inches Model Number S(..0 (0 1/1)- )/o Lit-- Install date Installed on 0 Floor r!i•-lall Number of Skimmers, Cr p THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION FtEquIREMENT$ By THE INSTALLER I declare that I hold an active California Statp Contractor license q 117 with classification (a I or a California State Professional Engineer license # 1 V3 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 Health & Safety Code Section 116064.2. Contractor/Engineer Name: im Ct/tiar— Company Name: of 144 Company Address: tO f r City: Rervecti JuJy 11,2010 Received Time Aug. 7. 2813 8:59AM No. 3397