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'alifornia Department of Public Healt' 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 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: Waterfield Square Pool Identification (if more than 1 pool/spa at site): 5 4 Facility Address: 8035 Mariners Square City: Stockton St: CA Zip: 95219 Owner Name: Equity Residential Owner's Phone Number: (866) 915-7978 Owner's Address: 2400 Camino Ramon City: San Ramon St: CA Zip: 94583 Pool constructed on or after January 1, 2010?: o Yes X No Pump Information A Recirculation Puitnp Make/Model R/ L--'K' Other Pump: Make/Model H.P Z. Jet /Booster Purfr Make/Model 1-A --- Feature Pump Make/Model H.P 2- S - 2 H.P 2 Main Drain (Includes All Suction Outlets Except Skimmer Equalizer Lines) , Manufacturer of approved drain cover: V`j''--k-'-"-t---- Model Number: CI4() ii 72. , V Install date I GPM rating: Floor 2,_57.,-, Wall ( Installed on A Floor 0 Wall ci - -(12e D Install date Manufacturer of approved drain cover: A - ue-, 54,- Model Number: 1- GPM rating: Floor Wall 7 Z Installed on o Floor Zi Wall Main drain/jet suction pipe size is inches Check One: '' / 2'/2 X 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) D Single drain — Not unb le (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravit ystem, auto pump shut-off system, or other equally or more effective system approved by enforcement agency)' Type of secondary device1nsta1141: Install date Manufacturer of approveCid -' e'vice:":, Model/Part Number: Safety vacuum release system bears thelol9wing performance markings: o ATSM F2387 0 ASME/ANSI standard A 112.19.17 THE ABOVE HAS BEEN FIELD VERIFIED TOACOMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Coritractor license # 929760 with classification C61/D35 or a California State Professional Engineer license # N/A 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 subjected to potential disciplinary action at the discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Name: Tom P. Hopper Company Address: 124-H Blossom Hill Road, #516 Contractor/Engineer Phone Number: (408) 225-4772 Contractor/Engineer FAX Number: (408) 225-4773 Tom P. Hopper 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 /(0 Company Name: PH Pool & Spa, Inc. State: CA Zip Code: 95123 Cell Phone 1\k,nnber: (408) 464-5945 E )ail: PHPOLS@YAHOO.COM I (!7 /1