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APPROVED BY: DATE: lifornia Department of Public Healti 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. oFFteE.USE ONLY op'. Li. LVIV IV. IYMM an Joaquin l,ounty No. 0652 This form is to be useeto 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: Facility Address: Owner Name; Owners Address City St. Zip Pool constructed on or after January 1, 2010?: 0 Yes 0 No Pump4nfomiatjon ecirculation c. o Jet / Booster Pump Make/Mode, 4,14.re4211:1 H.P /7. Make/Model 0 Other Pump: Feature Pump Make/Model 1-1,P Make/Model Main Drain Includes All Suction Outle Excep(. Skimmer Equalizer Lines1 Manufacturer of apgoved drain cover: Pl/r-f Model Number ..$-rx Install date 2- 7-/O GPM rating: Floor der all.") Installed on Er400r 0 Wall Manufacturer of approved drain cover: /` --,/p1.,i7 Model Number: 5 Install dale 1. ? Check One: GPM rating: Floor Wall Installed on o Floor Ball! Main drain/Jet suction pipe size is ' inches. _1:Z ) 0 Split main drain(s) (Minimum 3 (L between covers, hydraulically balanced and symmetrically plumbed) 0 Agte 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 Type of secondary device installed: ../. t-o system, or other equally or more effective system approved by enforcement agency) \ • Install date Manufacturer of approved device: 'WV (oil Model/Part Number: Safety vacuum release system bears the following performance standard markings: ED ATSM F2387 0 ASME/ANSI standard A 11219.17 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH ANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license if with classification 573 or a California Slate 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 ill impropedy 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. 110(P-7-77‘,? Company Name: //- State: Cell Phone Number: Cont or / ngineer name (PRINT) Con or rname (SIGNATURE) Dale For a complete text of the law, visit http://info.sen.ca.gov/put#09- 0/bilVasm/ab_1001-1050/ab _1020_bil1_20091011_chaptered.pdf Contractor/Engineer Name: Contractor/Engineer Phone Number: Company Address: City: Zip Code: .„9 Pool ldentifiCation (i! more than 1 pool/spa at sit ,q): City: ....S;(104/c/(75/1 Zip: Owner's Phone Number: H.P H.P