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JOB: 58929-2010 APPROVED BY: California Department of Public Health OFFICE U5E ONLY Compliance Form Anti -Entrapment Devices and Systems DATE: for Public Pools and Spas Health and Safety Code Sections 115064.1 and 116064.2 NOTE: Use one form for each pump or multiple 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 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 Spa- recirc. pump Facility Name: Quail Ridge Association Pool Identification [f more than 1 poollspa at site): 95207 Facility Address: 2109 Cedar Ridge city: Stockton St: Ca zip Owner Name: Quail Ridge Association Owners Phone Number. Owners Address 2109 Cedar Ridge CRY Stockton SL Ca zip 95207 Pool constructed on or after January 1, 20107: Pumn Information l --I' Recirculation Pump I pet I Booster Pump _ akelModel Starite H.P 1 ' Alake/Model H•P ❑ Other Pump: O Feature Pump Make/Model H.P Make(Model RP Main Drain (Includes Ail Suction Outlets FxrAot Skimmer Equalizer Lines,] xxxl92-2212-0 07-20-10 Manufacturer of approved drain cover. Paramount SDX Retro Model Number. Install date - GPM rating: Floor 200 , Wall 192 Installed on ZFloor Q Wall . Manufacturer of approved drain cover. Model Number: Install date GPM rating: Floor Wall Installed on Floor Wall Main drain/Jet suction 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 (sae and shape that a human body cannot sufficiently block to create a suction entrapment) ❑Single drain - Not unblockeble (one of the following secondary devices required: safety vacuum release system, suction Ilmiting.vent system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved ed byenstall enforcement agency) Type of secondary device installed: Manufacturer of approved. device: Model)Part Number. - Safely vacuum release system bears the following performance standard markings: O ATSM F2387 ❑ASME/ANSI standard A 112.19.17 Install date Skimmer Equalizer IJne(s1 Aqua Star 6" Hockey Puck 6HP 101 07-20-10 Manufacturer of approved suction filling: Y _ Model Number. GPM rating: GPM rating: Floor 53.6-224 well 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 1 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 impropedy certify this information, 1 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 ' Burkett's Pool Plastering, Inc. Contractor/Engineer Name: Company Name: Company Address: P.O- Box 938 city. Salida State: Ca Contrataor'Engineer Phone Number: 209 599-3317 —Cell Phone Number. 209 599-1701 Contractor/Engineer FAX Number: _ Email: Robert R. Burkett Contractor / Engineer name (PRINT) ontractor / E ineer name For a complete text of the law, visit: http://lnfo.sen,ca.gov/pub109.101bl1l/asm/ab_1001-lc Code: y5dbd 08-16-10 Date Revised: July 14, 2010