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JOB: 58929-2060 s . ~ APPROVED BY: DATE: California Department of Public Health Compliance Form Anti -Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 OFFICE USE ONLY NOTE: Use one form for each pump or multiple pumps 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 apublic 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 Quail Ridge Association Pool Identification (f more than 1 poollspa at site): Facility Name. . Facility Address: 2109 Cedar Ridge city: Stockton St: Ca zip: 95207 Quail Ridge Association Owners Phone Number. 209 644-4915 Owner Name: g Owners Address 2109 Cedaf Ridge city Stockton - SL Ca 7Jp 95207 Pool constructed on or after January 1, 20107: U Yes Information Pum Information - et I Booster Pump ✓ Recrf Pump ake/Model Starite H.P 1.5 . ake/Model H.P 0 Other Pump: o Feature Pump - H.P Make/Model H.P MakelModel Main Drain (Includes All Suction OutlRt� Exraot Skimmer Eeualizer Lineal 10AV101 existinh Manufacturer of approved drain cover.- Aqua Star10" Round Model Number. Install date GPM rating: Floor- 206 Wall 96 Installed on ZFIoor 0 Wall . Manufacturer of approved drain cover:Model Number: ; Install date GPM rating: Floor Wali Installed on Floor Nall Main drein/Jet suction pipe size is 2 inches. Check One: - .. . m 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: safely vacuum release system, suction limiting -vent system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by datenforcement agency) Type of secondary device installed: Install Manufacturer of approved. device: - - Model/Parl Number- - Safety vacuum release system bears the following performance standard markings: o ATSM F2387 ❑ASMEJANSI standard A 112.19.17 Skimmer EgualizerLlne(s) 6HP 101 07-20-10 Manufacturer of approved suction fitting: Aqua Star 6" Hockey Puck Model Number. Install date GPM rating: GPM rating: Floor 53.6-224 Wail 53.6-224 Installed on[] Floor Z Wall Skimmer equalizer line(s) pipe size were found to be 2 inches Number of Skimmers: 2 _ 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 053_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 subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health 8 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 elle ion�e Number. Contractor/Engineer FAX Number: 209 599-1701 i�y�� t " 09-22-10 Robert R. Burkett Contractor / Engineer name (PRINT) Contractor / Engi er name (SIGNATOR) Date c,., n n mnlafn f>xt of the law- visit: htto://Infe.sen.ca.gov/pub/09-10/bill/asm/ab 1001-10501ab 1020_blll 20091011 chaptered.pdf ReniaeJ: My 14, 2010