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California Department of Public Health Compliance Form Anti-Entrapment Devices and Systems for Public Pools and Spas OFFICE USE ONLY JOB: APPROVED SY! DATE: Health and Safety Code Sections 116084.1 and 11 .2 NOTE: Use one form for each Pump or multiple PUITIRI un eanasdill nqf-v-jr?-• 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 1141064.2. Under Section 116084.2 (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. Pool Identification (if more than 1 pooVspa at site) i)0:11. oyot.10 Facility Address: City: St Zip: Owner Name: Owners Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 2010'71 0 Yes I No Pumoird Recirculation Pam iy eke/Model y4 H.P 7_7 11 sire/Model I Booster Pump H.P Other Pump: Feature Pump MakelModel H.P akelMixiel H.P. Staln_DEgnilnCludes All Suction Outlets Exceet Skinnier &waltzer Until Manufacturer of approved drain cover: _Akitk 4- Model niumocr. 31.41:111f1001 Install date GPM rating: Floor IT Wall VA Installed on Nrloor 0 Wail Manufacturer of approved drain cover: Model Number. Install date GPM rating: Floor Wall Installed on11Floor 0 Wall Main drain/Jet suction pipe size is / i i inches. Chock One: [- .] Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) 0 Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) I-7 Single drain - Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent I—I 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: 0 ATSM F2387 0 ASMEJANSibteTId4rd *112.19.17 Skirrimr Eauplizer Unt(e) Manufacturer of approved suction fitting: WO& d91141- Model Numberig ttilt110665 Install date GPM rating: GPM rating: Floor 116 Wall 20S Installed on [—boor PliWall Skimmer equalizer fine(s) pipe size were found to be AP inches Number of Skimmers: . THE ABOVE HAS BEEN_FIELD VERIFJf.p TO CQVPLYVVITh MANUFACTURER'S RISTALLATION REQUIREMENTS I3Y THE INSTALLER I Oeclare that I hold an active California State Contractor license # 608182 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 Pool Plastering, Inc. Company Address: P.O. Box 938 City: Salida State: Ca Zip Code: 95368 ContractortEngineer Phone Number: 209 599-3317 Cell Phone Number Contractor/Engineer FAX Number 209 599-3317 Email: Robert R. Buricett Contractor I Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) Date For a complete text of the law, visit http:Ilirrlo.sen.ca.gov/pub/09-10/bilUesm/ab_1001-1050fab_1020_b111_20091011_chaptered.pdf Revised: JUN 14, 2010 utintumasm Facility Name: C\ic