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JOB: 108389-2019 SanJoaqu .. 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 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 Stone ate A tS Spa-Booster Facility Name: 9 p Pool Identification(if more than 1 pool/spa at site): Facility Address: 1451 W Center ST City Manteca st: ca zip: 95337 Owner Name: Owner's Phone Number: owners Address City St._Zip Pool constructed on or after January 1,2010?: ❑ Yes ■ No Pump Information Recirculation Pumpat/Booster Pump 2 ake/Model_ H.P -44ake/Model Whisperflo HP Other Pump: ❑Feature Pump ake(Model H.P_ Make/Model —H.P_ Main Drain(Includes All Suction Outleft Ezceot skimmer Equalizer Lln m A10RC FR 1 01 1-3-1 9 Manufacturer of approved drain cover Aqua Star10" Rd-sumpless Model Numoer. Install date GPM rating:Floor 170 Wall Installed on Wrloor ❑WeP Manufacturer of approved drain cover: -Model Number: Install date GPM rating: Floor Wall Installed on[]Floor []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 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 by enforcement agency) Type of secondary device installed: Install date Manufacturer of approved device: __._ ModeUPart Number. Safety vacuum release system bears the following performance standard markings:D ATSM F2307 D ASME/ANSI standard A 112.19.17 Skimmer Eausllzer Llne(s) Manufacturer of approved suction fitting: Model Number. Install date GPM rating:GPM rating: Floor Wall Installed on Dloor Dwell Skimmer equalizer finals)pipe size were found to be inches Number of Skimmers: 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 California 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 Information,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: BurketTs 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. 209 599-3317 Email: Robert R. Burkett O-lift 2-22-19 Contractor I Engineer name(PRINT) Contractor/Engineer name(SIGNATURE) Date For a complete text of the law,visit: http://info.sen.ca.govfpubM9-10/hill/awNab 1001-1050(ab 1020 blll 20091011 chaptered.pdf ReN .J*ir,2010