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AkJCQ Job 58584-2010 APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form Anti-Entrapment Devices and Systems DATE: for Public Pools and Spas 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 end 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 ang-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 The Shores HOAPool Facility Name: Pool IdentificaBon Cif more than 1 poollspa at site): Facility Address: 3801 Monitor Circle North City:Stockton St: Ca zip: 95219 Owner Name: The Shores HOA Owners Phone Number. Owners Address 3822 Moniter Circle North City Stockton SL Ca 71p 95219 Pool constructed on or after January 1 20107: LJ Yes ZNo j Pum Information Recirculation Pump I^patlBooster Pump akelModel Hayward H.P 2 E— 'ake/Mpdel H•P j ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain(Includes All Suction Outlntx Except Skimmer Equalizer Linesl xxx192-2212-0 07-13-10 Manufacturer of approved!rein cover. Paramount SDX Retro Model Number. Install date - GPM rating:Floor 200 . Wail 192 Installed on®Floor 0 Wall Manufacturer of approved draln cover. Model Number: N - Install date GPM rating:Floor Wall Installed on Floor Mall Main drain/Jetsuctlon 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(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 vent system,gravity drainage system,auto pump shut-off system,or other equally or more effective system approved byenforcement agency) Type of secondary device installed: Install date Manufacturer of approved device: - Model)Pan Number. - - Safety vacuum release system bears the following performance standard markings:❑ ATSM F2387©ASMFJANSI standard A 112 19.17 Skimmer EgualizerUne(s) 6HP 101 07-13-10 Manufacturer of approved suction fitting:2-Aqua Star 6" Hockey Puck Model Number. Install date GPM rating:GPM rating:Floor 53.6-224 wall 53.6-224 Installed on[]Floor Z Wall Skimmer equalizer line(s)pipe size were found to be 2 inches Number of Skimmers:-2 — 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. 35 or a California State Professional Engineer license# with quali0ed 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 11 i3064.2, Contractor/engineerNama: 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 Cell Phone Number. Contractor/Engineer FAX Number., 209 599-1701 mai' Robert R. Burkett 08-10-10 Contractor/Engineer name(PRINT) Contra or 1 Enginsjr name(SIGN T Dale For a complete text of the law,visit: http://Info.sen,ca,govfpub/09.101blIl/asmlab 1001-1050/ab-1 -bill-20091011 chaptered.pdf Revs :Jury 14,410