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APPROVED BY: CaEicrnia Department of Public Health Compliance Form OFFICE USE ONLY DATE: Anti-Entrapment Devices and Systems 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: Pacific Commons Pool Identification (if more than 1 pool/spa at site): West Pool Facility Address: 504 Northbank Ct City: Stockton St: CA Zip: 95207 Owner Name: Owner's Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 2010?: O Yes X No Pump Information Xi Recirculation Pump 0 Jet / Booster Pump Make/Model Hayward Super II H.P 12E-T 4 Make/Model H.P CI Other Pump: 0 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: Paramount Model Number: SDX Install date 2008 GPM rating: Floor 200 Wall Installed on X Floor Li Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on u Floor Li Wall Main drain/Jet suction pipe size is 2 inches. Check One: CI Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) O 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: SVRS Install date 4-2009 Manufacturer of approved device: Vacless Model/Part Number: Safety vacuum release system bears the following performance standard markings: Li ATSM F2387 X ASME/ANSI standard A 112.19.17 Breather 1-ADJ Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: GPM rating: GPM rating: Floor Wall 70 8AVV101 Install date 6-2010 Installed on ii Floor X Wall Aquastar Model Number: Skimmer equalizer line(s) pipe size were found to be 1.5 inches Number of Skimmers: 2 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 # 824920 with classification C61 -035or 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: 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: 209.84T3305 Email: Tim@Hemplemans.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