Form CPSC 120 CPSC 120 Verification of Compliance Form

U.S. Consumer Product Safety Commission
Virginia Graeme Baker Pool and Spa Safety Act
Verification of Compliance Form
COMPLETE A FORM FOR EACH PUMP AT A FACILITY

PART I – Pool Management Information
Investigator Name

Date of Inspection

Facility Name

Pool License/Permit Number

Address

Phone Number
(
State

City
Contact Name
Contact Address
City
Email Address

)
Zip Code

Title
State
Fax #

Zip Code

PART II – POOL/SPA Information
Pool Location

Indoor

Outdoor

Water Park

Other

Pool Type

Swimming
Pool

Wading
Pool

Spa

Other
________

Hot tub

Water Features (if any)

Spray

Slide

Hydro-jet

Volume of Pool (Gallons)

Mfgr, Make, Model Number, Horse Power of Pump

Other
________

Part III – Drain Covers
Total Number of Drain Covers in Pool/Spa
Name of Manufacturer of Drain Covers

Drain
Cover

Drain Cover
Dimensions &
Shape (Round,
Rectangular,
Square, etc.)

Total Number of Drain Covers Installed for VGBA Compliance

____________________________ Drain Cover Expiration Date (s)_______________________

Drain Cover &
Frame
Make and Model
Number

Date Installed &
Location
(Wall or Floor)

Cover Flow Rate per
Manufacturer
Specifications
(gallons per minute)

Pump Flow Rate
(gallons per
minute)

Cover Conforms to
ASME/ANSI A112.19.8-2007
or newer standard
(Indicate Yes/No)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Note: Attach documentation that the drain covers comply with ASME/ANSI A112.19.8 performance standard.
(i.e. Professional Engineerinspection report )

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Part IV Anti-Entrapment Device/System
1.

2.

Single Main Drain
Yes
No
Is this an unblockable drain that is larger than 18 x 23?

Yes

No

( If no, go to next section)

Multi-Drain System Yes
No
Is the multi-drain system at least three (3) feet from pipe center to pipe center? Yes
(See Attachment I, page 4) (If no, go to next section)

No

Select Secondary Backup System that is installed
Compliant Safety Vacuum Release System (SVRS) (Compliant with ASME/ANSI A112.19.17 or ASTM-F2387)
SVRS Mfgr. Name and Model ________________________________________________________________________
Suction- Limiting Vent System
Mfgr. Name and Model Number ________________________________________________________________________
_
Gravity Drainage System ______________________________________________________________________________
Automatic Pump Shutoff System _______________________________________________________________________
Mfgr. Name and Model Number _______________________________________________________________________
Drain Disablement
Describe how this was accomplished? ____________________________________________________________________
Other ______________________________________________________________________________________________
Comments_______________________________________________________________________________________________ _
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Part V Sump – Equalizer Lines
Sump Size
Width ________________

Depth

___________________

Length

________________________

Is Sump existing or new _____________
Is it field fabricated or manufactured
______________________________
Describe how it is fabricated? ________________________________________________________________________________
(If field fabricated, attach copy of certification from Professional Engineer)
Manufacturer Name and Model Number ________________________

Installation Date ___________________

Clearance between the bottom of the cover and the opening of the suction pipe is _______________________ (inches)

Equalizer Lines:
Are equalizer lines disabled? (Yes/No) (If so, describe how) ____________________________________________________________
Do equalizer lines have covers that cannot be removed? (Yes/No)
Describe how this was accomplished _______________________________________________________________________________
Provide manufacturer name AND model number for each equalizer cover _______________________________________________
Installation Date ________________________________________________________________________________________________

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Part VI Comments
If pool is not in full compliance , provide a description of actions or steps needed to bring pool or spa into compliance with
the Virginia Graeme Baker Pool and Spa Safety Act or attach timeline provided by the pool manager or documentation
that drain covers have been ordered.
Comments
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

_____________________________
CPSC In vestigator - Print Name

______________________
Signature

___________________
Date

Note: This form must be completed by CPSC staff or the designated State or local government
official.
The Consumer Product Safety Commission has requested approval from the Office of Management
and Budget for the collection of information associated with this form. In the absence of such an
approval, you are not required to provide the information requested to complete this form.

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CORRECT
3 FEET APART OR MORE

CORRECT
3 FEET APART OUTMOST OUTLETS

Dual Drain Outlets

Multiple Drain Outlets

Incorrect
LESS THAN 3 FEET APART

Incorrect
LESS THAN 3 FEET APART FROM OUTMOST OUTLET

4