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JOB: 89223-2015 „ L/ k PCI fa ac SanJoaquin County SR0073091 California Department of Public Health Compliance Form And-Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 APPROVED BY: OFFICE USE ONLY DATE: NOTE: Use one form for each puma 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 the 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 North Point Villas SPA Facility Name: Pool Identification (if more than 1 pool/spa at site). 6775 Cumberland PI City: Stockton 951219 Facility Address: Owner Name; TREFOXX PROPERTY MGMT Owners Phone Number. St2:0:9::9C5AZ2ip-:0;tip0095207 Owners Address 5345 N EL DORADO #8 city STOCKTON Pool constructed on or after January 1, 20107: L: Yes 1 No Pump information v Recirculation Pump Flet I Booster PurnP Make/Model STARITE H.P 1.5 ake/Model H.P 4tOther Pump: Feature Pump ake/Model _H.P Make/Model H.P Main Drain (Includes All Suction Outiolt Fxcnrat Skimmer Ectualizer Ling Al ORC FR101 Aqua Stan 0" Rd-sumpless 10-103-15 Manufacturer of approved drain cover: Model ixurnoer: Install date GPM rating: Floor 170 Wall Installed on V:loor 0 Wall Manufacturer of approved drain cover: . Model Number: Install date _ _.. GPM rating: Floor Wall installed onr—Floor [Wall Main drain/Jet suction pipe size is 2 inches, Check One: 12 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) El Single drain— Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) ri 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: i . . .._. Model/Part Number: Safety vacuum release system bears the following performance standard markings: ID ATSM F2387 m ASME/ANSI standard A 112.19.17 Skimmer Equalizer Line(s) Aqua Star 10" round/ sui Al ORCFR101 10-13-15 Model Number: Manufacturer of approved suction fitting: Install date GPM rating: GPM rating: Floor 170 Wall Installed on V 'Ioor FlWall SHARED COVERS WITH MD Skimmer equalizer line(s) pipe size were found to be 2 inches Number of Skimmers: 1 THE ABOVE HAS BEEN FIELD VERIFIEQ TO cOMPLY WITH MANUFACTURER'S JNSTALIATION REQUIREMENTS HY THE INSTALLER 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 Celt Phone Number: Contractor/Engineer FAX Number: 209 599-3317 Email: Robert R. Burkett 10-16-15 Contractor / Engineer name (PRINT) Contrectokpngineer name (SIGNATURE) Date For a complete text of the law, visit: http:Ifinfo.sen.ca.gov/pub109-10/billiasmiab_1001-1050lab_1020_13ill_20091011_chaptered.pdf State: Ca Zip Code: 95368 fRevisacl: July 14, 2010