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APPROVED BY: California Department of Public Health OFFICE USE ONLY Compliance Form FA: Anti -Entrapment Devices and Systems PR: DATE: for Public Pools and Spas SR: 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: Lakeview Condominium Pool Identification (if more than 1 pool/spa at site): Facility Address: 1511 South Mills Ave City: Lodi Owner Name: Lakeview Condominium Owners Address 1511 South Mills Ave City Lodi Pool constructed on or after January 1, 2010?: ❑ Yes © No St: Ca. Zip: 95242 Owner's Phone Number: 209-369-1963 Ca. Zip 95242 Pump Information © Recirculation Pump ❑ Jet/ Booster Pump Make/Model PantalrMisphemoWFE-0 H.P1.0 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 Sumpless Model Number: AlORCRF101 Install date 10-18-18 GPM rating: Floor170 Wall 170 Installed on A Floor ❑ Wall Manufacturer of approved drain cover: Aquastar Sumpless Model Number: AIORCRF101 Install date 10-18-18 GPM rating: Floor 170 Wall 170 Installed on o Floor ❑ Wall Main drain/Jet suction pipe size is 2.0 inches. Check One: X 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) Cl 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: Model/Part Number: Safety vacuum release system bears the following performance standard markings: ❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer Equalizer Lines) Manufacturer of approved suction fitting: Aquastar Sumpless GPM rating: GPM rating: Floor 170 170 Model Number: AlORCRF101 Install date 10-18-18 Installed on o Floor ❑ Wall Skimmer equalizer line(s) pipe size were found to be 1.5 inches Number of Skimmers: 1 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 # 923575 with classification C-53 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. 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 & Safety Code Section 116064.2. Contractor/Engineer Name: Christopher Curtis Company Name: Diamond Pools & Spas Inc. Company Address: 7361 wagon wheel Lane City: vawville Contractor/Engineer Phone Number: 707-151-4748 Contractor/Engineer FAX Number: 707-448-3787 Contractor / Engineer name For a complete text of the law, visit: State: Ca. Code: 95688 Cell Phone Number: 707-372-4756 Email: chits@dlamondpools.org CUrtIS oi.. miameiwaeararov 10-18-18 actor / Engineer name (SIGNATURE) Date 01bill/asm/ab_1001-1050/ab_1020_bill_20091011 _chaptered.pdf Revised: Ady 14, 2010