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APPROVED BY: DATE: 107298-2018 JOB: OFFICE USE ONLY SAN JOAQUIN COUNTY California Department of Public Health Compliance Form 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 PURIM 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 1160641 (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 antl-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 VVATERSTONE APTS Facility Name: Facility Address: 1951 W MIDDLEFIELD DR Owner Name: MG PROPERTIES, AGENT 858 366-6539 Owners Address City Pool constructed on or after January 1, 20107: 0 Yes 1 No SPA Pool Identification (if more than 1 pool/spa at site): City TRACY St: ca Zip: 95377 Owners Phone Number. 209 830-1580 St. Zip Pump Information Recirculation Pump ake/Model VVhisperflo Fir I Booster Pump H.P 3 ake/Model H.P M ake/Model Pump: Feature Pump Make/Model H.P Main Drain (Includes All Suction Ouflefs Excerit Skimmer Eaualbter Lines" Al ORCFR101 Aqua Star10" Rd-sumpless 12-4-18 Manufacturer of approved drain cover: M del Numoer. Install date GPM rating: Floor 170 Wall Installed on LLjloor 0 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 2.5 inches. Check One: lit 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 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: U ATSM F2387 o ASME/ANSI standard A 112.19.17 Skimmer Eauailzer NONE Manufacturer of approved suction fitting: Model Number: GPM rating: GPM rating: Floor Wall Installed on Skimmer equalizer line(s) pipe size were found to be inches Number of Skimmers: Install date "ioor Wall THE ABOVE HAS BEEN_FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLEF( 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 Contractor/Engineer Phone Number 209 599-3317 Cell Phone Number State: Ca Zip Code: 95368 Contractor/Engineer FAX Number 209 599-3317 Robert R. Burkett Email: , bGt-laibtt 1-28-19 Contractor / Engineer name (PRINT) Contractor Engineer name (SIGNATURE) Date For a complete text of the law, visit: http:Ilinfo.sen.ca.gov/pub/OS-101billiasmiab_1001-10501ab_1020_bill_20091011_chaptered.pdf Revised: July 14, 2010