COMPLIANCE INFO_PRE-2020 - Laserfiche WebLink

Home Browse Search

'2alifornia 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): fi leL oc) ( 8035 Mariners Square City: Stockton St: CA Zip: 95219 Facility Address: Equity Residential Owner's Phone Number: (866) 915-7978 Owner Name: 2400 Camino Ramon City: San Ramon St: CA Zip: 94583 Owner's Address: Li Yes A No Pool constructed on or after January 1, 2010?: Pump Information A Recirculation Plump Make/Model k El Other Pump: Make/Model H.P Main Drain (Includes All Suction Outlets ept Skimmer Equalizer Lines) Manufacturer of approved drain cover: ---it-- v,--- c -.-s t/Ac- Model Number: ,5 ), Install date I I ,-er._ I - /1 GPM rating: Floor 2 0 z.--' Wall . Installed on A Floor El Wall Manufacturer of approved drain cover: ilk. .....— e-r- Model Number: L/ 1Z--/---D Install date / I 1 C / / ,-- GPM rating: Floor Wall 77. 2.- Installed on Ei Floor X Wall Main drain/jet suction pipe size is 2.- lz- inches Check One: 0 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) p 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 I 1 IS I I° Manufacturer of approved device: -V , Model/Part Number: SIZ- - Safety vacuum release system bears the following perf6rmance markings: Ei ATSM F2387 Li ASME/ANSI standard A 112.19.17 A Li Jet /Booster Pump H.P Make/Model H.P ED Feature Pump Make/Model H.P THE ABOVE HAS BEEN FIELD VERIFIED TO oky WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California Stat a5 0- license # 929760 with classification C61/D35 or a California State Professional Engineer license # N/A with ci*fiedVoerience working on public swimming pools and that the information provided above is true to the best of my knowledge. I urICieria.nfthat if I improperly certify this information, I shall be subjected to potential disciplinary action at the discretion of the licensini:auth0:6 in accordance with California Health & Safety Code Section 116064.2. , Contractor/Engineer Name: TorpritiOie Company Address: 124-H Blovoir0410 itbad, #516 Contractor/Engineer Phone Nurrir: (408) 225-4772 Contractor/Engineer FAX Number: (408) 225-4773 Company Name: PH Pool & Spa, Inc. State: CA Zip Code: 95123 ell Phone Nu ber: (408) 464-5945 mail: IL @YAHOO.COM ( i ( Tom P. Hopper Contractor! Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) Date For a comniete text of the law. visit: htto://info.sen.ca.gov/oub/09-10/bill/asm/ab 1001-1050/ab 1020 bill 20091011 chantered.odf