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APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form FA: Anti-Entrapment Devices and Systems PR: DATE: for Public Pools and Spas SR: Health and Safety Code Sections 116064.1 and 116064.2 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. 116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010, the owner of a public swimmini shall file this form within 30 days following the completion of construction or Installation of ant"Wrapment devices or syste swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approv+ permits prior to construction or remodel. Site Information Facility Name: SUMMERPLACE HOA Pool Identification(if more than 1 pool/spa at site): SPA Facility Address: 8318 MANHATTAN DR. Cit,. STOCKTON St: CA Zip:95210 Owner Name: Owner's Phone Number: Owners Address City St._Zip Pool constructed on or after January 1,2010?: ❑ Yes A No Pump Information * Recirculation Pump ❑ Jet/Booster Pump Make/Model H.P Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain (Includes All Suction Outlets Except Skimmer Equalizer Lines) Manufacturer of approved drain cover: AQUA STARS ____Model Number: A-10 RCFR Install date 6/10/2020 GPM rating: Floor170 Wall Installed on O Floor C 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 inches Check One: * 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: safety vacuum release system,suction limiting v, system,gravity drainage system,auto pump shut-off system,or other equally or more effective system approved by enforcement a! Type of secondary device installed: Install date Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings:O ATSM F2387 ❑ ASME/ANSI standard A 112.19.1 i Skimmer Equalizer Lines) Manufacturer of approved suction fitting: NA Model Number: Install date GPM rating:GPM rating: Floor Wall Installed on ❑Floor ❑ Wall Skimmer equalizer line(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 BY THE INSTALI I declare that I hold an active Califomia State Contractor license# 767721 with classification C-53 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: MIKE MCDONELL Company Name: ADAMS POOL SPECIALTIES Company Address: 7 WAYNE CT. City: SACTO State: CA Zip Code: 95629 Contractor/Engineer Phone Number: 916 388 2000 Cell Phone Number: 916-9976787 Contractor/Engineer FAX Number: 916.388-2001 Email: ODONELL@ AMSPOOL.NET MIKE MCDONELL - l Contractor/Engineer name(PRINT) Conctor/Engineer name(SIGNATURE) Date For a complete text of the law,visit: http://info.sen.ca.gov/pub109-10/bill/asmlab-1001-1050/ab 1020—bill-20091011—chaptered.pdf