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Jos: #140490 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 ft*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. [Mati Facility Name:Namelon HarVeSt In Tracy Pool Identification(if more than 1 poollspa at site): Spa Facility Address: 2655 Henley Parkway city. Tracy st:j�'dLzip: 95377 Owner Name: Rand / Manager Owner's Phone Number. 916-403-1705 Owners Address City St. Zip Pool constructed on or after January 1, 2010?: 0 Yes ■ No Purno Information Pentair Recirculation Pump et 1 Booster Pump ake/Model H.P_3 ake/Model H.P nOther Pump: ❑Feature Pump —Make/Model I _H.P_ Make/Model_ H.P Main Drain(Includes All Suction Outlets Excent Skimmer Eaualizer Lines! A10RCFR101 Manufacturer of approved drain cover: Aquastar 10" Rounds Model Number. �nstail date 01/6/2025 GPM rating: Floor 170 Wall Installed on oloor ❑wall Manufacturer of approved drain cover:_ _Model Number: Install date GPM rating: Floor Wall Installed on❑Floor []Wall Main drain/Jet suction pipe size is �inches. Check One: © Split main drain(s)(Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ❑ Single drain--Unblockabie(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 1/6/2(l25 Manufacturer of approved device: - - ._ Model/Part Number: Safety vacuum release system bears the following performance standard markings:❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer EaualizerLine(s) ABANDONED Manufacturer of approved suction fitting: Model Number: Install date GPM rating:GPM rating: Floor Wall Installed on Dloor ❑Wall AUTOFILL Skimmer equalizer line(s)pipe size were found to be inches Number of Skimmers: 2 THE ABOVE HAS Q VERIFIED TO COMPLY_WITtI MANUFACTURER'S INSTALL&TIQN REQUIREMENTS BY THE INSIAALE 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 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 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: 96368 Contractor/Engineer Phone Number: 209 599-3317 Cell Phone Number: Contractor/Engineer FAX Number: 209 599-3317 Email: Robert R. Burkett kau&t 6aal= 01/6/2025 Contractor/Engineer name(PRINT) Contractor/Engineer name(SIGNATURE) Date For a complete text of the law,visit: http://info.son.ca.gov/pub/09.101billioemlab_1001-1050(ab_1020_bill_20091011 chaptered.pdf Revised:duly 14,2010