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JOB: X8929-2010 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 multi Pie oumos 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 116364.2 (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 Spa -Booster Facility Name: Quail Ridge Association Pool Identification if more than 1 pool/spa at site): 2109 Cedar Ride Cit Facility Address: 9 y' Stockton St: Ca. zip: 95207 Owner Name: Quail Ridge Association Ownees Phone Number. Owners Address 2109 Cedar Ridge CRY Stockton St Ca Zip 95207 Pool constructed on or after January 1, 20107: U Yes I'll formation Razirculation Pump - atisoosterPump Purn H.P caakelMadel Staflte H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make(Model H1.P Main Drain (Includes All Suction Outlets Fxcent Skimmer Eaualizer Lineal xxxl92-2212-0 � 07-20-10 ' Manufacturer of approved drain cover.' Paramount SDX Retro Model Number. Install date GPM rating: Floor 200 _ Wail 192 Installed on ®Floor 0 Wall . Manufacturer of approved drain cover. Model Number: s Install date GPM rating: Floor Wall Installed on Floor Dwall Main drabWetsuollon pipe size is 2 inches. Check One: . . m 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) E] Single dram - Not unblockable (one of the following secondary devices required: safely 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: ModellPart Number. - c..r..a....�....,....ere��a �fam hears the fhllowine performance standard maddngs: O ATSM F2367 ❑ASMFJANSI standard A 112.19.17 Skimmer Equalizer Line(s) Aqua Star 6" Hocke Pck 6HP 101 07-20-10 Manufacturer of approved suction filling: Q _ yu_ Model Number. Install date GPM rating: GPM rating: Floor 53.6-224 Wall 53.6-224 Installed on❑ Floor 0 Wall Skimmer equalizer line(s) pipe size were found to be 2 inches Number of Skimmers: 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. 35 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 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. Contractor/Engineer Name: Robert R. Burkett Company Name: Burkett's Pool Plastering, Inc. Company Address: P.O. Box 938 City: Salida State: Ca Contra. _'E (neer Phone Number. 209 599-3317 Cell Phone Number. 209 599-1701 Contractor/Engineer FAX Robert R. Burkett Contractor! Engineer name (PRINT) For a complete text of the law, visit: http://Info.sen.ca Email: er name 1001-1C Zip Code: 95368 08-16-10 Date Ravi :July 14, N10