VGBA COMPLIANCE DATA SHEET
Name and address of pool:______________________________________________________________
Pool location:
Indoor __________
Outdoor__________
Pool type:
Swimming Pool__________
Wading Pool__________
Water features: Hydrotherapy Pump_______
_____________
Slide_______
Spa____________
Waterfall______ Other______ N/A
Volume of pool (gallons) _______________________
Pump information Manufacturer_______________________ Make __________________Model Number_____________
HP of Pump___________ Flow Rate (GPM) ____________ (MULTIPLE PUMPS REQUIRE INDIVIDUAL DATA SHEETS)
Drain cover information Manufacturer__________________ Make __________________Model Number_____________
Date Installed_____________________________
Location of installation Floor __________
Wall ____________
Expiration Date of Drain Covers _________________________________________________________________________
Dimensions of Drain Cover (inches) _______________
Shape (round, rectangular, square, etc.)____________________
Flow rate of drain cover in gallons per minute (GPM) ________________________________________________________
Drain cover conforms to ASME/ANSI A112.19.8-2007 or newer standard:
Yes__________
No__________
Single Main Drain:
Yes__________
No__________
Is this drain larger than 18”x23”
Multi-drain system
Yes____
No_____ N/A ______
Yes____
No_____ N/A ______
Is the multi-drain at least 3’ from pipe center to pipe center
(If no, go to Secondary Back up System)
Yes____
No_____ N/A ______
Distance (inches) __________
Secondary Back up System - Safety Vacuum Release System (SVRS) compliant with ASME/ANSI A112.19.17 or ASTM-F2387.
Stingl (Make and Model) ___________________________ Vac Alert (Make & Model)_____________________
Other (Make and Model)______________________________________ N/A _____________________________
Sump information Manufacturer _______________________ Make __________________ Model __________________
Width (inches)_________________
Depth (inches)_______________________
Is the sump?
_________
Existing
Is the sump field Fabricated? _________
Date sump installed___________________
or
or
Length (inches)______________
New _________
Manufactured? _________
Size of suction pipe (inches) ______________
Clearance between the bottom of the drain cover and the opening of suction pipe (inches)
__________________________
Equalizer line cover information Manufacturer ____________________ Make _________ Model #__________________
Flow Rate (GPM) __________________ Equalizer line cover installation date____________ Expiration Date____________
Size of Equalizer lines ________ (inches) # of Equalizer line covers __________ N/A _______________
Owner/Operator/PE (title) Signature ______________________
“Healthy People, Safe Environment, Strong Community”
EHS005
7-2015