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JOB: 110795-2019 Sa , Joaquin County APPROVED I California Department of Public Health OFFICE USE ONLY Compliance Form Ami-Entrapment Devices and Systems DATE; for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one forth for each pump or multiple Dumps under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form Is to be used to verity 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 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 Pool Facility Name: Neplus Apartments Pool Identification(if more than 1 pool/spa at site): FacilityAddress: 321 Neplus Ct CityLodi yt:LA_7up: 95242 Owner Name: Beacon Property Management, Agent Owner's Phone Number: 209 333-2700 owners Address 1194 W Tokay St Ste 1 City Lodi SL Ca c zip 95240 Pool constructed on or after January 1.2010?: o Yes ■ No Pump Information Recirculation Pump F-)et I Booster Pump eke/Model_ StaRite H.P 1/2 '�IAake/Model H.P �Other Pump: ❑Feature Pump ake/Model H.P Make/Model _H.P Main Drain finciudes All Suction OtAlab Eraapt 9klmmsr Equalizer Lineal A 1 0 RC F R 1 01 g-18-19 Manufacturer of approved drain cover. Aqua Star10" Rd-sumpless M del Numoer. Install date GPM rating:Floor 170 Wall Installed on /door ❑Wall Manufacturer of approved drain cover: _Model Number. Install date GPM rating: Floor Wall Installed onDloor ❑Wall Main drain/Jet suction pipe size is 2 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 unblorkable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system,gravity drainage system,auto pump shut-off system,or other equally or more effective system approved by enforcement agency) 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 112.19.17 Skimmer EausllzerLine(s) Aqua Star 10" round/ Sup A10RCFR101 9-18-19 Manufacturer of approved suction fitting: Model Number. Install date GPM rating: GPM rating: Floor Wall 170 Installed on door ©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 or a Califomia State Professional Engineer license# with qualified experience working on public swimming pools and that the information provided above is We to the best of my knowledge. I understand that if I Improperly certify this intfornaton, 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 Celt Phone Number. Contractor/Engineer FAX Number. 209 599-3317 Email: Robert R. Burkett O_&/Lt uAltft 10-2-19 Contractor/Engineer name(PRIMO Contractor/Engineer name(SIGNATURE) Date For a complete text of the law,visit: http:/Iinfo.sen.ca.govlpuWG9-10/bill/auNab 1001.105Gfab 1020—bill-20091017 chaptered.pdf Rem MY 14,2010