COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

Job 55023- 07-2009 APPROVED BY: California Department of Public Health OF Compliance Form Anti-Entrapment Devices and Systems PATE: for Public Pools and Spas AIL 2 Y 111 Health and Safety Code Sections 116464.1 and 116064.2 ENVIRUNwLN I HEALTH NOTE: Use one form for each pump or multi le pumps under the same drain cover. PERMIT/SERVICES 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 fomn 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. I Site Information Pool Sahara Mobile Court Facility Name: Pool Identification (if more than 1 poolispa at site): j 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_ _St.Ca zip 94566 Pool constructed on or after January 1,20107: LJ Yes No ' I Pump Information Recirculation Pump IF� st 1 Booster Pump akelModel Ha and Pro rid H•P 1 L—MakelModel H.P O Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H:P Main Dr In(Includes All 5uctlon outlAt-,FXnant Skimmer Eaualizer Linesl 32CDFLFR101 08-14-09 Manufacturer of approved drain cover: Aqua Star Channel Drain Model Numbor. Install dale GPM rating:Floor 31.6 Wall 208 installed on ZFloor 0 Wall Manufacturer of approved drain cover: Model Number: ___Install date GPM rating:Floor Wall Installed on DFloor[]Wall Main drainlJet suction pipe size is 2 inches. Check One: ❑Split main draln(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: ModellPart Number: Safety vacuum release system bears the following performance standard markings:❑ ATSM F2387❑ASME/ANSI standard A 112.49.17 Skimmer Equalizer LJne s NIA Manufacturer of approved suction fitting: Model Number: Install date GPM rating:GPM rating:Floor Wall Installed on[]Floor []wall Skimmer equalizer Ilne(s)pipe size were found to be inches Number of Skimmers: 2 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS 13Y THE INSTALLER declare that I hold an active California State Contractor license f1 60 182 with classification C53. 35 or a California State Professional Engineer license# with qualified experience working on public swimming pools and that the informadon 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 8 Safety Code Section 116064.2, Robert R. Burkett corn Name: Burkett's Pool Plastering, Inc. Contractor/Engineer Name: Pan Y Company Address: P.O. Box 938 City: Salida state: Ca Zip Code: 95368 Contra ctorlEngineer Phone Number: 209 599-3317 Cell Phone Number: ContractorlEngineer FAX Number. 209599-1701 Email: Robert R. Burkett ' Contractor 1 Engineer name(PRINT) _ViContractor 1 Engineer name(51GNAT } Date For a complete text of the law,visit: http:lflnfo.sen.ca.gov/publO9-101bIIIlasmtab_1001-1050lab-102 _blit 20091011„ohaptered.pdf ReVwed:July 14,2611+