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California Department of Public Health APPROVED BY: OFFICE USE ONLY Compliance Form FA: i. Anti-Entrapment Devices and Systems PR: DATE: for Public Pools and Spas SR: Health and Safety Code Sections 116064.1 and 116064.2 NOTE:Use one form for each pump or multiple i3umps 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 file 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 priarto construction or remodel. Site InforrnaEtion Facility Name: 24 Hr Fitness Pool Identification(if more than 1 poollspa at site): Spa.tet Facility Address: 1020 North Main Street ! City: Manteca St: Ca. Zip;95336 Owner Name: 24 Hr Fitness i Owners Phone Number. 209-825-4141 1020 North Main Street Manteca Ca. 85336 Owners Address City St. Zip Pool constricted on or after January 1,2010?: ❑ Yes 9 No Pump Information • Recirculation Pump Ei Jet I Booster Pump Make/Model H.P Make/Model Starits136UG-2061- x2pLanps H_P 1.5 ❑ Other Pump: ❑ Feature Pump Make/Model I H.P Make/Model H.P _Main Drain(includes All Suction Outlets Except Skimmer Egualizer Lines) Manufacturer of approved drain cover: Aquastar Model Number. A811101 Install date 11-20-2019 GPM rating: Floor 125 Wall 84 Installed on ❑Floor o Wall Manufacturer,of approved drain cover Aquastar Model Number: ASR101 Install date 11-20-2019 GPM rating: Floor 125 Wall 84 Installed on ❑Floor ©Wall Main drain/Jet suction pipe size is 2.0 inches. Check One: A Split main drain(s)(Minimum.3 ft.between covers, hydraulically balanced and symmetrically plumbed) ❑ Single 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: Model/Part Number: Safety vacuum release system bears the fallowing performance standard markings:ID ATSM F2387 ❑ ASME/ANSI standard A 112.19-17 Skimmer Euualizer Line(s) Manufacturer of approved suction fitting: N-A Model Number: Install date GPM rating:GPM rating: Floor Wall Installed on ❑Floor ❑ Wali Skimmer equalizer line(s)pipe size were found to be inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license# 923575 with classification C53 or a California State Professional Engineer license# with qualified experience working on public swimming pools and that the information provided abiove is true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disciplinary!Sction at the discretion of the licensing authority in accordance with California Health&Safety Code Section 116064.2. Enginee Contractorl' r Name: Christopher Curtis Company Name: Diamond Pools&Spas Inc. Company= 7351 Wagon wheel Lane City: VacavilIle State: Ca Zip Code: 95688 Contractor/engineer Phone Number. 707.451-4748 Cell Phone Number. 707-372-4756 Contractor/Engineer FAX Number: 707-448.4748 Email: chris iamo I Christopher Gunis christopher curtis ^ ^ 11-20-2019 Contractor I Engineer name(PRINT) Contractor 1 Engineer name(SI TURE) pate For a Complete text of the law,visit: http:/linfo.sen.ca.gov/pub/09-101bili/asm/ab_1001-1050/ab-1020—bill-20091011_Chaptered.pdf I , Revis"t July 14,2610