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APPROVED BY: , DATE: JOB: 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(1 NOTE: Use one form for each_oumo or multiple PLIMPP under the same drain cover. AU. SECTIONS OF THIS FORM MUST BE COMPLETED. This form Is to be used to verify compliance vAth 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 fite this form within 30 days follovAng 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. Pool Identification (if more than 1 pooVspa at site):WOL Facility Address: City: St Zip: Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 20107: r] Yes 1 No Pumo lnformatloil Reeirculationlys_rn Make/Model Other Pump: akeiModel 0141A416 H.P tYL —M let I Booster Pump r_Iake/Model H.P Feature Pump H.P Make/Model H.P Skimmer &waltzer Line"' 14_ odel niumuer.31tpfLfikvesi install date Installed on loor 0 Wall Model Number: _ Install date Installed on Floor 0 Walt Main drain/Jet suction pipe size is VI inches. Check One: 0 Split main drain(s) (Minimum 3 ft between covers, hydraulically balanced and symmetrically plumbed) Single drain - Unbiockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) I Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent ' system, gravity drainage system, auto pump shut-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: ID ATSM F2387 a ASME/ANSI-standard -A 112,19.17 Skimmer Eauld Or Line(11) Manufacturer of approved suction frtting 1:kka, Model Number' NIX%t Install date GPM rating: GPM rating: Floor%Ic Wall C. Installed on 1 hoof' Wall Skimmer equalizer line(s) pipe size were found to be \ h inches Number of Skimmers: 1.. THE ABOVE HASJBF-EN_FIELD VERIFIED JO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license* 808182 with classification C53 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 Health & Safety Code Section 116064.2. Contractor/Engineer Name: Robert R. Burkett Company Name: Burkett'S POD! Plastering, Inc_ Company Address: P.O. Box 938 City Salida State: Ca Zip Code: 95368 Contractor/Engineer Phone Number: 209 599-3317 Cell Phone Number Contractor/Engineer FAX Number: 209 599-3317 Emelt Robert R. Burkett Contractor / Engineer name (PRINT) Contractor I Engineer name (SIGNATURE) Date For a complete text of the law, visit httpdlinfo.sen.ca.gov/pubf09-10/billteernfab_1001-1050feb_1020_b111_20091011_chaptered.pdf Revised: July 14, 2510 OFFICE USE ONLY Site infoasation yr) . Facifity Name: 1--(1 Main Drain (Includes All Suction Outi Manufacturer of approved drain cover. n als GPM rating: Floor blip We di Manufacturer of approved drain cover: GPM rating: Floor Wail