CPSC 120 Compliance Verification Form

Virginia Graeme Baker Pool and Spa Safety Act Verification of Compliance Form

FINAL VGBA Checklist - REVISED-8-24-11-OMB -3041-0142 (2)

OMB: 3041-0142

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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 OMB Control Number: 3041-0142

Investigator Name


Date of Inspection



Facility Name


Pool License/Permit Number


Address


Phone Number

( )

City


State

Zip Code

Contact Name

Title

Contact Address

City

State

Zip Code

Email Address

Fax #



PART II – POOL/SPA Information


Pool Location


Indoor


Outdoor


Water Park


Other







Pool Type


Swimming

Pool


Wading

Pool

S pa


Hot tub

Other

________




Water Features (if any)


Spray


Slide


Hydro-jet

O ther

________


Volume of Pool (Gallons)


Mfr, Make, Model Number, Horse Power of Pump


Part III – Drain Covers


Total Number of Drain Covers in Pool/Spa Total Number of Drain Covers Installed for VGBA Compliance


Name of Manufacturer of Drain Covers ____________________________ Drain Cover Expiration Date (s)_______________________








Drain

Cover

Drain Cover

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


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)





























































Note: Attach documentation that the drain covers comply with ASME A112.19.8 or successor performance standard ANSI/APSP-16 (effective Sept. 6, 2011). (i.e. Professional Engineer inspection report )




Part IV Anti-Entrapment Device/System



1. 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)


2. Multi-Drain System Yes No

Is the multi-drain system at least three (3) feet from pipe center to pipe center? Yes No

(See Attachment I, page 4) (If no, go to next section)



Select Secondary Backup System that is installed


Compliant Safety Vacuum Release System (SVRS) (Compliant with ASME/ANSI A112.19.17 or ASTM-F2387)

SVRS Mfr. Name and Model ________________________________________________________________________


Suction- Limiting Vent System

Mfr. Name and Model Number ________________________________________________________________________

_

Gravity Drainage System ______________________________________________________________________________


Automatic Pump Shutoff System _______________________________________________________________________

Mfr. 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 ________________________________________________________________________________________________





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 Investigator - Print Name Signature Date





CPSC Form 120 (07/10)


Note: This form must be completed by CPSC staff or the designated State or local government official.































CORRECT CORRECT


3 FEET APART OR MORE 3 FEET APART OUTMOST OUTLETS

Dual Drain Outlets Multiple Drain Outlets



Incorrect Incorrect


LESS THAN 3 FEET APART LESS THAN 3 FEET APART FROM OUTMOST OUTLET























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File Typeapplication/msword
File TitleDecember 1999
AuthorPat Dean Brick
Last Modified Bylglatz
File Modified2011-08-25
File Created2011-08-25

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