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OFFICR USE ONLY <br />Fee Paid $ INSTALLATION CERTIFICATION <br />vG0 DRAIN COVER & SECONDARY DEVICE <br />APPROVED By <br />0.8TE: FA. <br />PR: <br />NOTE: Use one forrn for ea iiL punv or multiple pumpis kinder the same cover. <br />For the property named Fili:eirt b <br />SR: <br />Osier <br />located at g boo IT. IA/0 " California, I hereby certify that pursuant to California State Health & Safety Code Sec. 164.1 and 116004.2, that an Anti-en apment cover meeting the current standards of the American Society <br />-. <br />of Mechanical Engineers (ASME)/ANSI performance standard and where required, a secondary safety device meeting the current ASME/ANSI <br />orASTM perlormance standards have been installed per the manufacturer's instructions on the: <br />)31 <br />Swimming Pool t-Cl.tit(--, <br />Spa Jet / Booster di.".L1 <br />Spa Recirculation <br />Wading/toddler pool <br />1.-/e,(1(ja fk$ bap/ H.P -)--f ° ; Flow (,gpm)_ LI Z' <br />H.P ; Flow (gpm) <br />A C/ LA A--\1;•- <br />,.1 . i <br />Model/Pari Number: I 'L---I (C-1 I C-) I GPM rating: Floo <br />Cover bears the following markings: <br />0 'VGB 2008 or later, <br />C "ASME/ANSI standard A 112.19.8-2007 or later', <br />Main rain/Jet suction pipe size is 1/ inches. Manufacturers mein drain"(Ls°)es;J:rnp depth requirement in inches is: 3 <br />i <br />Single drain - Not unalockable (one of the following secondary devices required: SVRS / Suction limiting vent / gravity drainage/ <br />auto pump shut-off/ other approved by enforcement agency) ,--. , i /1 , Type of Secondary device installed; r g , ,:, V (-N > <br />Manufacturer of approved device: \t/Ci( C PtICL i -A-- Model/Part Number; \JA)., Ck-"Y-i c,, SVRS nears the following markings: <br />0.00,•A..STM F2387", <br />IIEV, .r."AtMEJANSI standard A 112.19.17', <br />t trktitre„ffirietalling a variable speed SVRS pump a RPM/Time Data sheet shall be faxed to EMD at 875-8513 following <br />1tteinarta1linian, (A sample form is available from the Environmental Health Plan Review office) L'i fat6le'clraln"t'444Iiickable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 0 ‘. \Dual main.,d(tin(s) <br />f:\ .• r- <br />ettii0zer,lintati: <br />Manufacturer of approved cover: fatiA/4 0 dr* <br />Mode/Part Number: &Pk GPM rating: Floor •Vii ' Wall It/Installed on 0 Wall o Floor C "VGB 2008 or later', <br />le "ASME/ANSI standard A 1 12.19.8-2007 or later. 'Life": <br />Skimmer equalizer line(s) pipe size were found to be ir ..( _inches it of Skimmers: Z---- <br />6 KI7 <br />051. 14'14 <br />111411 JP <br />deciase that I hold an active California State Contractor license It _25.--c"/ 121 or California State Professional Engineer license it e 3 , with qualified experience working on public swimming pools and that the information provided above is true to the best of my knowledge. l'rri aware that improper certification of the above information shall be subject to potential disciplinary action at me etis n of the licensing authority. <br />Print me <br />DUt cer /3 - 2-0 ture <br />Date <br />!act Name \rri . Phone 90 p-cqp-syri email <br />MENT DUE PRIOR TO APPROVAL CALL PLAN REVIEW AT (916) 974-6010 <br />For a complete text of the law, visit: <br />http:/anfo,sen,ca.qovitsuo/09-10/bIlliasm/ab 1001.1 DSOlae 1020 bill 20091j1 chap_gered,011 <br />8I/Gt 30t/e1 <br />At/EI NOROIN - - - • - <br />LTIEIL8Lt7602T:°1 <br /> Obi IL9S9T6 <br /> <br />ObTIL9S916:w0 Jd 2t7:0T TT02-t70-Ntlf <br />Existing Pump(s) Make/Model <br />Make/Model <br />Main Drain(s): <br />Manufacturer of approved cover: <br />61, Wall_ , installed on o WalLkiFloor <br />Manufacturer's skimmer equaiizer line(s) sump depth requirement in inches is: <br />C.11 Single equerizer line <br />Cl Dual Skimmer equalizer line(s) sump depth inches kit Skimmers are connected with single line to Puma, <br />Skimmers are separately valved before pump and can be isolated.