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o n APPROVED 13Y: DATE: OFFICE USE ONLY 2f10 250 alcnt--t --Avc JOB: 60012:2010'• 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 116084.2 NOTE: Use one form for each oumo or multiple Pumas under the same drain cover. AU.. SECTIONS OF MIS 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 loan within 30 days following the completion of construction or Installation of and-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 Tiffany Estates Facility Name: Pool Identification (if more than 1 pool/spa at site): Pool Facility Address: 209 Tiffany Circle City Ripon st: Ca Zip: 95366 owner Name: Tiffany Estates owner's Phone Number: Owners Address 209 Tiffany Circle City Ripon st. Ca Zip 95366 Pool constructed on or after January 1, 20107: 0 Yes M No polnfonnsUon Pentair H.P VS fljet I Booster Pump H.P Recirculation Pump eke/Model VS+SVRS flouter Pump: UFeature Pump Make/Model H.P e/Model 11.P. Main Drain (Includes All Suction Outlets Excerpt Skimmer Eauatizer Lineal xxx-192-2212 Install date 11-12-10 Manufacturer of approved drain cover Paramount SDX retro Model Number GPM rating: Floor 200 Wall 196 Installed on Dloor I:I wail Manufacturer of approved drain cover: Model Number Install date GPM rating. Floor Wall Installed on0Floor 0 Wall Main drain/Jet suction pipe size is , 1 5 inches. Check One: 0 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) p Single drain — Unblocicable (size and shape that a human body cannot sufficiently block to create a suction entrapment) gi Single drain — Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent L.' system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved Install by Yitee 1 1-1 2-10 Manufacturer Type of secondary device installed: Pentair Intelliflo SV+SVRS Manufacturer of approved dot - - - . .. -- . Model/Part Number SV+SVRS Safety vacuum release system bears the following performance standard markings: 0 ATSM F2387 0 ASME/ANSI standard A 112.1a17 Skimmer Enuallar tine(st 11-12-10 Manufacturer of approved suction fitting: Ternp. Plugged* Model Number Install date GPM rating: GPM rating: Floor Wall Installed on Dloor Dwell *plugged until next plaster Skimmer equalizer line(s) pipe size were found to he 1.5 inches Number of Skimmers: 2 gri THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY INFTH MANUFACTURER'S INSTALLATION REQUIREMENTS )3Y THE INSTALLER I declare that I hold an active California State Contractor license a 608182 vAth classification C53 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 il l 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 Secdon 116064.2. Contractor/Engineer Name: Robert R. Burkett Company Name: Burketts Pool Plastering, Inc. Company Address: P.O. SOX 938 City: Salida State: Ca Zip Code: 95366 Contractor/Engineer Phone Number 209 599-3317 Cell Phone Number Contractor/Engineer FAX Number 209 939-3317 %Ail /ADA Email: Robert R. Burkett ''‘ A .i._0 12-07-10 Contractor / Engineer name (PRINT) ContaGrf glneer name tGNATURE) Date For a complete text of the law, visit hdp://info.sen.ca.gov/publ09-10Ibilll 1001-1050/ab 1020_bill_20091011_chaptered.pdf — %stud Jilv 14, 2010