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JOB: - 66124-2012 APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form And-Entrapment Devices and Systeme DATE: for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE:Use one form for each Dump or muMpie Dumas under 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 now Health and Safety Code sections 116064.1 and 1160&4.2. 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 Inatalladon 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. She Information Eastwood manor HOAPool Facility Name: Pool Identification(if more than 1 pooyspa at site): Facility Address: 146 E. Grant Line Rd. —city: Tracy st: CA zip: 95376 Owner Name: Owners Phone Number: 209 952-9400 Owners Address city SL_Zip Pool constructed on or after January 1,2010?: o Yes ■ No Plop Information Hayward IV I Recirculation Pump Fllet/Booster Pump ake/Model_ Tri Star H.P 1 L--Make/Model H.P [—]Other Pump: _ ❑Feature Pump ``---Make/Model H.P Make/Model_ H.P Main Drain(Includes All Suction Ougafs Fxcant Skimmer Enualiaer Lined 32CDFLFR101 Manufacturer of approved drain cover. Channel Drain Model mumour. Install date 6-27-12 GPM rating:Floor 316 wall 208 Installed on /door []Wall Manufacturer of approved drain cover: ��LL_Model Number Install date GPM rating: Ft=—Wall Installed on[]Floor❑Wall Main drain/Jet suction pipe size is 2, inches. Check One: Split main drain(s)(Minimum 3 R. between covers, hydraulically balanced and symmetrically plumbed) ® Single drain—Unblodkable(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 shutoff 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 following performance standard markings:o ATSM F2387 o ASME/ANSI standard A 11219.17 SkknmerEdualizerune(s) Channel Drain 32CDFLFR101 6-27-12 Manufacturer of approved suction fitting: Model Number Install date GPM rating:GPM rabrg: Floor 316 Wall 208 Installed on Dlor Zwall Skimmer equalizer lines)pipe size were found to be 2 inches Number of Sldmmers: 1 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# 608182 with classification C53 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!lest of my knowledge. I understand that'd I Improperly certify this information,I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance 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 Contractor/Engineer Phone Number: 209 599-3317 Cell Phone Number. Contractor/Engineer FAX Number. 209 599-3317 j} Email: Robert R. Burkett OJAACQ—� 7-2-12 Contractor/Engineer name(PRINT) T Contractor! Inver name(SIG 'URE) Date For a complete text of the law,visit Mtiti1 info.sen.ca.gov/publ09-10/bliV A 1001-105dab 1020—b111-20091011—chaptemd.pdf ftBN W MY 14,2010