CPSC 120 Compliance Verification 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 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

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__________________________________________________________________________________________________

__________________________________________________________________________________________________

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_____________________________ ______________________ ___________________

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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