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J12512524-2021-22 SAN JOAQUIN COUNTY SR0084602 <br /> State of California—Health and Human Services Agency <br /> VWPH California Department of Public Health <br /> Anti-Entrapment Deices and Systems for Public Pools and Spas Compliance <br /> NOTE: Use one form for each pump or multiple pumps under the same drain cover. <br /> ALL SECTIONS OF THIS FORM MUST BE COMPLETED, <br /> This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections <br /> 116064.1 and 116064.2, Under Section 116064.2 (a) of the Health and Safety Code, effective ,January 1, 2010; the owner of <br /> a public swimming pool shall file this form within 30 days following the completion of construction or installation of anti- <br /> entrapment devices or systems In swimming pools. Contact your local Environmental Health Department and Building <br /> Department for any necessary plan approval and permits prior to construction or remodel. <br /> Site Information <br /> Facility Name: WINE & ROSES HOTEL Pool Identification (if more than 1 poollspa at site): EAST SPA mm <br /> Facility Address:_2505 W Turner Rd City: Lodi St; CA zip: 95242 <br /> Owner Name: Owner's Phone Number., 209 625-5862 <br /> Owners Address City St: Zip <br /> Pool constructed on or after January 1,201.07: u Yes m No <br /> Pump Information <br /> q ecirculation Pump ❑O Jet I Booster Pump <br /> LM_fflakeWodel PENTAIR INTELLIFLO 1 3 Make/Model H.P <br /> [[]Other Pump: ®Feature Pump <br /> Make/Model H.P Make/Model H.P <br /> Main Drain Includes All Suction Outlets Except Skimmer Equalizer Lines) <br /> Manufacturer of approved drain cover: -AQUASTAR 10"SUMPLESS Model Number: A.10RCFR101 Install date 2-19-22 <br /> GPM rating: Floor 170 Wall Installed oloor BJUall <br />,I Manufacturer of approved drain cover: Todel Number: Install.date <br /> CPM rating: Floor Wall Installed on ❑ loor Dhall Main drain/Jet suction pipe size is 2.5 inches. <br /> Check One: <br /> ®Split main draln(s)(Minimum 3 ft. between covers,hydraulically balanced and symmetrically plumbed) <br /> Dingle drain—Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) <br /> FJSingle drain—Not unblockable(one of the following secondary devices required:safety vacuum release system,suction limiting vent <br /> system,gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agency) <br /> Type of secondary device installed: Install date W <br /> Manufacturer of approved device: Model/Part Number: <br /> Safety vacuum release system bears the following performance standard markings: o ATSM F2387 ORSME/ANS1 standard A 112.19.17 <br /> Skimmer E ualizer Line s <br /> Manufacturer of approved suction fitting: ABANDON Model Number: Install date <br /> GPM rating: GPM rating:Floor Wall Installed oOO loorEo Nall AUTO FILL DEVICE <br /> Skimmer equalizer line(s)pipe size were found to be N/A inches Number of Skimmers: 1 <br /> Ci 8005(3117) Page 1 of 3 <br />