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JOB: APPROVED BY: California Department of Public Health Compliance Form Anti-Entrapment Devices and Systems DATE: 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 mum drain cover. AU. 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 1160642. 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 antkintrapment devices or systems In swimming pools. Contact your local Environmental Health Deperbrient and Building Department for any necessary plan approval and permits prior to construction or remodel m2infongszn Facility Name: W fiL71- (-)1 /it Pool identification (if more than 1 pool/spa at site)i filltSt is 5cih Facility Address: City: St Zip: Owner Name: Owners Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 2010?: 0 Yes 1 No P Int 111-3 •Recirculation Pump Qiet H.P I ll / Booster Pipe ake/Model Verig" LAVAPC01* 1Y H.P t eke/Model \,..1\iNditiCAL Feature Pump Make/Model I-100w Pump: HP eke/Model Mika/rain iffiCilithtS Ail Suction gyllets Exceot Skimmer Enualizer Linait Manufacturer of approved drain cover dliksot Model Nuniuelle:Ofirtr.km Install date GPM rating: Floor ' Wall Installed on loor 0 Wall Manufacturer of approved drain cover: _64.itt4t1a. Model Number. \b ak\1111)4&, Install date Wall . _ . GPM rating: Floor ILlii Installed oratiFroor LI Wall Main drain/Jet suction pipe size is . `21° inches. Check One: Li Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced one symmetrically plumbed) 0 Single drain - Unbicckable (size and shape that a human body cannot sufficiently block to create a suction entrapment) fl Single drain - Not unblcckable (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: 0 ATSM F2387 a ASME/ANSi-sLrldadA 112.19.17 Skimmer Ectualitter Line(*) Manufacturer of approved suction fitting: \\)/A4,_ Model Number Install date GPM rating: GPM rating: Floor Wall Installed on Door LiWall Skimmer equalizer line(s) pipe size were found to be inches Number of Skimmers: THE ABOVE HAS BEFALFIF_LD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER ( declare that I hold an active California State Contractor license* 608102 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 8 Safety Code Section 116084_2. Contractor/Engineer Name: Robert R. Burkett Company Name; Bur-1(401a Pool 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 Email: Robert R. Burkett Contractor / Engineer name (PRINT) Contractor I Engineer name (SIGNATURE) Date For a complete text of the law, visit http:I/Info.sen.ca.gov/pubf09-10/bill/asmiab_1001-101501ab_1020_bill_20091011_chapteriaid.pdf Jutv 14,2010