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HP inches OFFICE USE ONLY APPROVED SY. 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 NOTE; Use one form for each pump 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 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. Pool Idenlifica ion (if more than 1 poo spa at site) Betk__ City St (fit., Zip - Owner's Phone Number DATE: 'Linty Information Recirculation P Make/Model 0 Other Pump: Make/Model ritgyiR,ç 2,0a H P 21 0 HP _ lanufacturer Of apPrOved drain cover Facility Address Owner Name Owners Address Pool constructed on or after January 1 2010->: ;PM rating: Fioor Wall 'hr One: Site Information Facility Name Fri( Fri th 0 Yes .4( No Feature Pump Make/Model City St. Zip J 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) evice: bea rs the following perfor ance standard markings devices required: safety vacuum release system, suction limiting vent other equally Or more effective system approved by enforcem nt agency) Install date 1— — Model/Part Number 0 ATSM F2387 ASME/ANSI standard A 112.19 17 suction fitting: fairl-/vM.It/YVI": Wall Model Number:,5:4"). ok" Installed on 0 Floor 0 Wall Install date jj- vo THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMENTS BY THE INSTALLER declare that I hold an active California State Contractor license # 7<_</L7 , with classification 3 or a California State )rofessionai Engineer license 1/ Ai* inches Number of SkimMers: ;ontractor/Engineer Name. .;ompany Address: 'Jer ry gokr-k, ;ontractor/Engineer Phone Number: ‘-ontraCtor/Engineer FAX Number: State: (14 Zip Code: Cell Phone Number: 9* s iiIiiI ail: (/,1.,4^ Gate -10/bill/asm/ab_1001-1050/ab_1020_bill_20091011_chaptered.pdf i'13 , UP/ e (SIGNATURE) Jet / Booster Pump Make/Model HP lain Drain Includes All Suction Outlet E e • t kimmer Equalizer Lines! lanufacturer of approved drain cover: 4.411*.n. el/ evr Model Number: ,,f1) .7 Install date ;PM rating: Floor --4.0,9 Wall 11 a Installed on %floor 0 Wall MOdel Number: Install dale Installed on 0 Floor p Wall Main drain/Jet suction pipe size is Single drain — Not unblockable (one of the following Secondary system. gravity dra system, auto pump shut-off system, Or Type of seconda%fI installed: ManufactureKtra Safety vacuum rstet Skimmer Equalikfr Vlanufacleitti*aciko 71314" 4114.g._ .\Cfikill'ating• Floor 3kommer NAlizer line(s) pipe size were found to be with qualified experience working on public swimming pools and that the information )rovided above is true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential iisciplinary action alms discretion of the licensing authority in accordance with California Health & Safety Code Section 116064 2. Company Name: Ler !It's pockvi, , NW A COn rktc7/ En i er name (PRINT) Ira. or E er n 'or a complete xl of the law, visit: http://info.sen.ca.gov/pu% I ReviS MI July 14 2010 Ot71U9S9I6:1"Jd 1102-17.21-Nt:If 110181t'6021 :01 Elt7T T2.9S9T6 6 /9:a6ed