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r Job 51906-2008 APPROVED 9Y: 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 pumas 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 prior to construction or remodel. Site Information Casa De Lodi Spa Facility Name: Pool Identification(if more than 1 pooUspe at site): j Facility Address: 812 E. Turner Rd. City:Lodi - St: Ca Zip, 95240 Owner Name: Owner's Phone Number. Owners Address Cfiy SC_zip Pool constructed on or after January 1 20107' Yes f No Pum Info ati n Rearculation Pump t/ et I Booster Pump 2 `7 ake/Model Emerson HP 2 �aka/Model Hayward H.P ❑ Other Pump: o Feature Pump Make/Model H.P MakelFAodel H:P Main Drain(includes Suet] utln riot skimmer ItzernLin ,,, WAV12101 05-15-08 Manufacturer of approved drain ver` Aqua Star 12 x 12 Wave umber. Install date GPM rating:Floor 361 r 0 Wall Manufacturer of approved drain cover. Model Number:,N Install date GPM rating:Floor Wall Installed on a Floor E/Jall Main drain/Jetsuction pipe size is 2 inches. Check One: - - m Split main draln(s)(Minimum 3 ft.between covers,hydraulically balanced and symmetrically plumbed) Single drain—Unblockabie(size and shape that a human body cannot sufFlclently block to create a suction entrapment) Single drain—Not unblockable (one of the following secondary devices required: safety vacuum release system,suction Ilmiting-vent system,gravity drainage system,auto pump shut-of system,or other equally or more effective system approved byenforcement agency) Type of secondary device installed: Install date Manufacturer of approved.device: ModellPan Number. - Safety vacuum release system bears the following performance standard markings:o ATSM F2387 aSMFIANSI standard A 112.49.17 Skimmer Equalizer llnefsl rl0 equalizer lines Install date Manufacturer of approved suction fitting: q Model Number. GPM rating:GPM rating:Floor Well Installed on❑Floor Wall Skimmer equalizer fine(s)pipe size were found to be inches Number of Skimmers: 1 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BYTHE INSTALLER I declare that 1 hold an alive California Slate Contractor license# 608182 with classification C53_35 or a California State Professional Engineer license# with qualified experience working on public swimming pods 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 sub)ect to potential disciplinary action at the d-iscretion 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 Ste: Ca zip code: 95368 City: Salida Contractor/Engineer Phone Number: 209599-3317 Cell Phone Number, Contractor/Engineer FAX Number: 209 599-1701_QL Email' Robert R. Burkett Contractor I Engineer name(PRINT) Contr ctor grocer name(SIG E) Data For a complete text of the law,visit• hffp://Info.sen.ca.govtpublog-loiblillesmiab- 1001.1050/ab_1020_ 091011 chapterad.pdf Ra M:jury14,wm