COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

108736-2019 SAN J DUIN COUNTY JOB: 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 Dumos 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 penults prior to construction or remodel. Site Information S U M M E RGATE HOASPA Facility Name: Pool Identification (if more than 1 pool/spa at site): Facility Address, 998 W GRANT LINE RD. City. TRACY gt:-ca Zip: 95376 Owner Name: Owner's Plane Number: Owners Address City St. Zip Pool constructed on or after January 1, 20107: D Yes 0 No Pump Information Recirculation Pump�/ atIBoosterPump STA RITE 2 LY—Make/Model _ STA RITE H.P 1 ake/Model H Other Pump:_ ❑Feature Pump akelModel -H. P- Make/Model H.P Main Drain (Includes All Suction Oapala Eseent Skimmer Enualizer Lined 24101 Manufacturer of approved drain cover. Aqua Star 24x24 M del rvumoer. Install date 4-4-19 GPM rating: Floor 1645 Wall Installed on0loor ❑ Wall Manufacturer of approved drain cover:_ moL_ Model Number. Install date GPM rating: Floor Wall Installed onlIFIoor []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) Q 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: _ _ ModeUPan Number: Safety vacuum release system bears the following performance standard markings: ❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer Eauallzer Lines) NONE Manufacturer of approved suction fitting: GPM rating: GPM rating: Floor Wall_ Skimmer equalizer lines) pipe size were found to be N/A Model Number: Install date Installed on Dkxx Elwell Number of Skimmers: 1 I declare that I hold an active California State Co. iii or license # 608182 with classification C53 or a California State -,;ll Professional Engineer license # with qualified experience working on public swimming pools and that the informatrdn 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 8 Safety Code Section 116064.2. ContractortEngineer Name: Robert R. Burkett Company Name: Burketts Pool Plastering, Inc. ^*r ,u Company Address: P.O. Box 938 City: Salida Contractor/Engineer Phone Number. 209 599-3317 State: Ca Cell Phone Number. Zip Code: 95368 Contractor/Engineer FAX Number. 209 599-3317 Email: Robert R. Burkett C—U it T 4-8-19 Contractor! Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) Date For a complete text of the law, visit: http:llinfo.son.ca.gov/pubIO9.10/bill/asnVab 1001-105Ofab 1020_blll 20091011 chaptered.pdf ReNse my 14, 2010