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Job 55023- 07-2009 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 pump or multiple pumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST SE 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 prior to construction or remodel, Site Information Pool racility Name: Sahara Mobile Court Pool identification (if more than 1 poollspa at site): i t Facility Address: 2340 Sanguinetti Ln. city:Stockton St: Ca. Zip: 95205 Owner Name: Bill Denhoy Owner's Phone Number. 530 357 4385 Owners Address 3780 West Ruby Hill Dr. City Pleasanton sL Ca zip 94566 Pool constructed on or after January 1,20107: Pum Information Recirculation Pump F-Iet/Booster Pump akelModel Ha ward Pro fid H.P 1 akelModel H•P ❑ Other Pump: ❑ Feature Puma MakelModel H.P MakelMadel H.P Main Drain Includes All Suction OutlPtr FYrRnt Skimmer Equalizer Lines, 32CDFLFR101 08-14-09 Manufacturer of approved drain cover: Aqua Star Channel Drain Model Number: Install date CPM rating: Floor 316 wall 208 installed on oFloor []Wall Manufacturer of approved drain cover. Model Number:-N _Install data GPM rating:Floor Wall Installed on 0 Floor[]Wall Main drainlJet suction pipe size is 2 inches. Check One_ F-1Split main drain(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 El system,gravity drainage system,auto pump shut-off system,or other equally or more effective system approved by enforcement agency) Install date Type of secondary device installed: Manufac=turer 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 E ualizer Lines NIA Manufacturer of approved suction fitting: Madel Number. install date_ GPM rating:GPM rating:Floor Wall Installed on[I Floor Wall Skimmer equalizer Ilre(s)pipe size were found to be inches Number of Skimmers: 2 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANVFACTURER'S INSTALLATION RE U1REMENTS By THE INSTALLER I declare that I hold an active California State Contractor license# QQ5182 with classification C5335 or a California State Professional Engineer license# with qualified experience working on public swlmming pools and that tiie 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 accordance with California Health&Safety Code Section 116064.2. Robert R. Burkett Company Name: Burkett's Pool Plastering, Inc. Contractor/Engineer Name: Company Address: P.O. Box 938 - - City: Salida State: Ca Zip Code: 95368 ContractorlEngineer Phone Number: 209 599-3317 Cell Prone Number: ContractorlEngineer FAX Number: 209 599-1701 Etna Robert R. Burkett l `� Contractor I Engineer name(PRINT) Contractor I Engineer name(StGNATURE� ale For a complete text of the law,visit: httpalinfo.sen.ca,govipub109.101bilIla smlab_1001.10501ab-1020-bill_20091011-ch aptered,pdf Revised:July 14,2oiLI