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JOB: 89223-2015 Uldia Pefl r a zsL_ San Joaquin County SR0073091 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 APPROVED BY: OFFICE USE ONLY DATE: 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 116084.2 (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 North Point Villas SPA Facility Name: Pool Identification (if more than 1 pool/spa at site): Facility Address: 6775 Cumberland PI city: Stockton St: CA zip: 951219 Owner Name: TREF0)0( PROPERTY MGMT Owner's Phone Number; 209 952-9400 Owners Address 5345_IY FL DORADO #8 city SToCKTON St, CA Zip 95207 Pool constructed on or after January 1, 2010?: 0 Yes 1 No Pump Information v Recirculation Pump et I Booster Pump Make/Model _ STARITE H.P 1.5 m ake/Model EtOther Pump: Li Feature Pump ake/Modet _HP_ Make/Model Main Drain Oncludes All Suction Outipts Fxcant SkImmar Enualizer Linsil Al ORCFR101 Aqua Star10" Rd-sumpless 10-103-15 Manufacturer of approved drain cover Model niumoer: Install date GPM rating: Floor 170 Wall Installed on V %or 0 Wall Manufacturer of approved drain cover: _ Model Number: install date GPM rating: Floor Wall Installed o _Floor 0 Wall Main drain/Jet suction pipe size is 2 inches, Check One: 2 Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) 0 Single drain.- Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) ni 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: 0 AISM F2387 0 ASME/ANSI standard A 112.19.17 Skimmer Eaualer Lineis)AlORCFR101 Aqua Star 10" round/ sul 10-13-15 Manufacturer of approved suction fitting: Model Number install date GPM rating: GPM rating: Floor 170 Wail Installed on rte7hoor 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 veRiFiep iv COMPLY WITH MANUFACTUREIn INSTALLATION REQUIREMENTS BY THE INS*. 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 inforrnatio provided above is true to the best of my knowledge. I understand that if I improperly certify this Information, I shall be subject to potentia13,---.7.'..At 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 State: Ca Zip Code: 95368 Contractor/Engineer Phone Number: 209 599-3317 Cell Phone Number: Contractor/Engineer FAX Number: 209 599-3317 f a____ Email: Robert R. Burkett 10-16-15 Contractor / Engineer name (PRINT) Contractce4ngineer name (SIGNATURE) Date For a complete text of the law, visit: http:Ifinfo.sen.ca.gov/pub/09-10/billtasmiab_1 001-1050fab_1020_3ill_20091011_chaptered.pdf RevisK1: July 14,2010