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JOB: 58585-2010 APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form Anti-Entrapment Devices and Systems DATE: for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each puma or multiple pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and 116064.2. Under Section 116064.2 (a)of the Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool shall fife this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site information Spa ` Quail TerraceApartments Facility Name: Pool Identification(if more than 1 poolfspa at site): Facility Address: 1744 Quail Lakes Dr. City:Stockton St: Ca. zip: 95207 Owner Name: Quail TerraceApartments Owner's Phone Number. 510 651-0990 Owners Address 1744 Quail Lakes Dr. City ,Stockton St Ca zip 95207 I Pool constructed on or after January 1,2010?: Li Yes 0 N IiI 4 Pumv Information Recirculation Pump et 1 Booster Pump ake/Modet Centurion H.P 1 aka/Model H.P ; ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain(includes All Suction Outlntc Fxr not Skimmer Eaualizer Linesl 32CDFLFR101 07-14-10 Manufacturer of approved drain cover: Aqua Star Channel Drain Model Number. Install date GPM rating:Floor 316 . Wall 208 Installed on ZFloor 0 Wall Manufacturer of approved drain cover. Model Number: Install date GPM rating:Floor Wall Installed on 0 Floor❑Wall Main drain/Jet suction pipe size is 2 inches. Check One: ❑Split main draln(s)(Minimum 3 ft.between covers,hydraulically balanced and symmetrically plumbed) ZSingle drain–Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) ❑ Single drain–Not unblockable (one of the following secondary devices required: safety vacuum release system,suction limiting vent system,gravity drainage system,auto pump shut-off system,or other equally or more effective system approved by enforcement agency) Type of secondary device installed: Install date Manufacturer of approved device: ModellPart Number. Safety vacuum release system bears the following performance standard markings:❑ ATSM F2387❑ASME/ANSi standard A 112.19.17 Skimmer Equalizer Unefs1 y Install date Aqua Star 6" Hockey Puck 6HP 101 07-14-10 Manufacturer of approved suction fitting: Model Number: GPM rating:GPM rating:Floor 53.6-224 wail 53.6-224 Installed on[]Floor a Wall Skimmer equalizer line(s)pipe size wore found to be 2 inches Number of Skimmers: 1 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that 1 hold an active California State Contractor license# 60� with classification C53, 35 or a California State Professional Engineer license# with qualified experience working on public swimming pools and that the information provided above is true to the best of my knowledge. I understand that if i improperly certify this information,I shall be subject to potential disciplinary action at the discretion of the licensing authority in aecordence with California Health&Safety Code Section 116064.2. Contractor/Engineer Name: Robert R. Burkett Company Name: Burkett's Pool Plastering, Inc. Company Address: P.O. Box 938 City: Salida State: Ca _. Zip Code: 95368 Contra ctor/Engineer Phone Number: 209 599-3317 Cell Phone Number.— ContractorlEngineer FAX Number: 209 599-1701 Email: Robert R. Burkett � 08-11_10 Contractor/Engineer name(PRINT) Contractor/E gineer na e f(SIGNAklbRDate For a complete text of the law,visit: http:/(info.sen.ca.gov/pub109-10/billiasm/ab_1001-1050/ab_1020_bili-20091011_chaptered.pdf Revered:July 14,2010