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Jab: 56255-2009 REVISED AB 1020 FOR COVER REPLACEMENT APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Forth - An"rWapment Devices and Systema DATE: for Public Pools and Spas Health and Be" Code Sections 116064.1 and ! 16064.2 NOTE: Use one torn for each gum R or muMole ounta under the same drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form Is to be used to weft compliance with modiflcatlons pursuant to the new Health and Safety Cods sections 116004.1 and 118004.2. Under Section 11410642 (a) of the Health and Be" Code, effective January 1, 2010, the owner of a public swimming pool shalt BN this form within 30 days following the completion of construction or Installation of on0ontrapment devices or systems In swimming pools. Contact your local Environmental Health Depaf+nent and Building Daparhnent for any necessary plan approval and permits prior to construction or remodel. site Information on Rj Unified School Pool Facility Name: p Pool IdentlBetttlon (if more then 1 poolfsPa at site): FacilityAddrass: 304 N Acacia City: Ripon St: Ca zip: 95366 Owner Name: Owner's Phone Number: Owners Address Pool constructed on or after January 1, 20107: a Yea ■ No zip Lqg Upper Pump US Electrical #6211 -22 -JC -3 / Booster Pump H.P.22 ekelModel H.P. p: Lower Pump- 22_ ❑FsaWm Pump #6312 -JC -3 H.P. .? MakelModel_ _H.P. Mein Drain flneludea All Suction Ouaara Excent Skimmer ECUS112e 242424SSMD-8 11-23-11 Manufacturerofapproveddrain co�4-Neptune Benson 24x2 1� .__ _.. Install date GPM rating: Floor 1432 Wall 1120 lnsta loo ❑ Wall . Manufacturer of approved drain cover:_ Imo_ Mie -f=oal Number Install date GPM rating: Floor Wall Installed onaloor LJ Well Main drainlJet suction pipe size is 10 inches. Check One: W] 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 unbloc kable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pump shut -oft system, or other equally or more effective system approved by enforcement agency) Type of secondary device installed Install data Manufacturer of approved davioe. -.... .. ModeUPart Number: Safety vacuum release system bears the following performance standard markings: o ATSM F2367 a ASME/ANSI standard A 112. 19.17 Skimmer Eauslizer Lints) Manufacturer of approved suction Offing: Model Number. Install date GPM rating: GPM rating Floor Wall Installed an D1oor Elwell Skimmer equalizer line(s) pipe size were found to be inches Number of Sklmmere: THE ARM HAe BEEN FIELD VERIFIED TO C(MMV WITH MAN F CT ecgn INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State contractor license # 608182 with classification 953 or a California State Professional Engineer license # with qualified expefence working on puMk: sWmming pools and that the information provided above is We to the best of my knowledge. 1 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 116084.2. Contractor/Engineer Name: Robert R. Burkett Company Name: Burkett's Pool Plastering Inc. Company Address: P.O. Box 938 City: Salida Stam: 9a zip Code: 95368 Cornractor/Engineer Phone Number. 209699-3317 Call Phone Number. Contractor/Engineer FAX Number: Robert R. Burkett Contractor / Engineer name For a complete text of the law, visit Emait. 11-28-11 Date %w AN1/4,1010