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APPROVED BY: DATE: JOB: California Department of Public Health Compliance Form Anntrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE; Use one form for each Immo 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 1160641 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 instaliatIon of anti-entrapment devices or systems In swimming pools. Contact your local Environmental Health Department arid Building Department for any necessary plan approval and permits prior to construction or remodel. Pool Identification (if more than 1 pool/spa at site):- 2 ,e,„ Facility Address: City: St: Zip: Owner Name: Owner a Phone Number: Owners Address City St. Zip Pool constructed on Of after January 1, 2010?: 0 Yes I No Pump lnforlTlaUun RecirculatIon,Pum ake/Model _WS YSIX) r_IFitlat I Booster Pump kelModel 1\,ANNY.A. fibv4 H Other Pump: liFesture Pump ake/Model _• . P Make/Model H.P Mein Drain (Include, All Suction Outlets Except Skimmer Eaualbter I_Intal Manufacturer of approved drain cover yak Model riuniuerih'Shlk(AV)0/ Install date GPM rating: Floor 03 Wall 10 Installed orik loor 0 Wall Manufacturer of approved drain cover 11... iiltt! Model Number: Ntittfit)t)OL Install date GPM rating: Floor \.i0 Wall lo Installed onL4ioor 0 Wall Main drain/Jet suction pipe size is VI, inches. Check One: Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced end symmetrically plumbed) . ErSingle drain - Unblocicable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 7 Single drain - Not untalockabie (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 beers the following performance standard markings: 0 ATSM F2387 0 ASME/ANSI-standard A112,19.17 Skimmer EGualipor Une(s) Manufacturer of approved suction fitting: Ilk* irk* Model Number IDPIAPOO(Ni install date GPM rating: GPM rating: Floor 1613 Wall It Installed on ElloorAVVall Skimmer equalizer line(s) pipe size were found to be 1.11 inches Number of Skimmers: THE ABOVE HAS Elgfa.FITELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIFtEMENTS pY THE INSTALLeR i declare that I hold an active California State Contractor license # 608182 vi4th 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 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: tittp://infoaen.ca.gov/Pub/09-10/billlasmfab_1001-10601ab_1020_bill_20091011_chaptenid.pdf Site lnfonnatton Facility Name: Pcivo Revised: it* 4. 201