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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 Facility Name: Almond Blossom Estates Pool Identification (if more than 1 pool/spa at site): Facility Address: 1901 E Yosemite City: Manteca St: CA Zip Owner Name: Owner's Phone Number: Owners Address city St. _ Zip Pool constructed on or after January 1, 2010?: ❑ Yes X No Pool 95336 Pump Information X Recirculation Pump ❑ Jet/ Booster Pump Make/Model Pentair WhisperFlo H.P 1.5 Make/Model H.P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain (Includes All Suction Outlets Except Skimmer Equalizer Lines) Manufacturer of approved drain cover: Aquastar Model Number: RLP8AVV101 Install date 12-2008 GPM rating: Floor 96 Wall Installed on XFloor ❑ Wall Manufacturer of approved drain cover: Model Number: date GPM rating: Floor Wall Installed on o 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) A 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: Both Permanently Disabled 12-2008 Install date Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard markings: o ATSM F2387 o ASME/ANSI standard A 112.19.17 suction fitting: Aquastar Model Number: 8AW101 Install date 6-2010 GPM ra :"Gpol rating: Floor Wall 70 Installed on ❑ Floor X Wall Skimmerequali gr line(s) pipe size were found to be 1.5 inches Number of Skimmers: 2 I declare ft. Mild an active California State Contractor license # 824920 with classification C61-C35or aCalifornia State Professi tsngineer license # with qualified experience working on public swimming pools and that the information provided 56gY¢'t$"true to the best of my knowledge. I understand that if I improperly certify this information, I shall be subject to potential disciplinajj2 �t the discretion of the Iicensinq authority in accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Name: Timothy E Hempleman Company Name: Hempleman's Pool Cures Company Address: 11749 Sawyer Ave City: Oakdale State: CA Zip Code: 95361 Contractor/Engineer Phone Number: 209.847.3305 Cell Phone Number: 209.614.6385 Contractor/Engineer FAX Number: 209.847.3305 Email: Tlm(cMemplemans.com Timothy E Hempleman- Contractor / Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) DaTe For a complete text of the law, visit: http://info.sen.ca.gov/pub/09-10/bill/asm/ab_1001-1050/ab_1020_bill-20091011_chaptered.pdf