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APPROVED BY: <br />DATE: <br />OFFICE USE ONLY <br />, JOB: 54130-2008 <br />California Department of Public Health <br />Compliance Form <br />Anti-Entrapment Devices and Systems <br />for Public Pools and Spas <br />Health and Safety Code Sections 116064.1 and 116064.2 <br />NOTE: Use one form for each pump or multiple pumps under the same drain cover. <br />ALL SECTIONS OF THIS FORM MUST BE COMPLETED. <br />This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and <br />116064.2. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1,2010, the owner of a public swimming pool <br />shall file this form within 30 days following the completion of construction or installation of anti-entrapment devices or systems in <br />swimming pools. Contact your local Environmental Health Department and Building Department for any necessary plan approval and <br />permits prior to construction or remodel. <br />Site Information Pool Tracy Park Apartments <br />Facility Name: Pool Identification (if ITIOfe than 1 pool/spa at site): <br />Tracy Park Apartments <br />St:2C09a 54Z4i p:349252376 Facility Address: <br /> <br /> City: Tracy 2800 N Tracy Blvd. <br />Owner Name: Owner's Phone Number <br />Owners Address 2800 N Tracy Blvd. <br />Pool constructed on or after January 1, 2010?: <br />Pump Information <br />j Recirculation Pump <br />v aketModel Champion <br />Aqua Star 8" Round 12-30-08 Main Drain (Includes All Suction OutIptn Fxr_ent Skimmer Eaualizer Lines_l 8AV101 <br />Manufacturer of approved drain cover. Model Number Install date <br />GPM rating: Floor 88 wail 70 Installed on ZFloor 0 Wall <br />Manufacturer of approved drain cover Model Number: \ Install date <br />GPM rating: Floor Wall Installed on 0 Floor LJWaiI Main drain/Jet suction pipe size is 2 inches. <br />Check One: <br />IZI Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) <br />El Single drain — Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) , <br />ri Single drain — Not unblockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent <br />' system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agency) <br />Type Of secondary device installed: Install date <br />Manufacturer of approved device: Model/Part Number: <br />Safety vacuum release system bears the following performance standard markings: 0 ATSM F2387 IIJASMEJANSI standard A 112.19.17 <br />o Other Pump: <br />Make/Model <br />City Tracy st Ca Zip 95376 <br />Yes No <br />H.P 2 <br />liet / Booster Pump <br /> ake/Model H.P <br />0 Feature Pump <br />Make/Model H.P H.P <br />Skimmer Equalizer Line(s) <br />Manufacturer of approved suction fitting: Aqua Star 8" Round <br />GPM rating: GPM rating: Floor 88 Wail 70 <br />8AV101 12-30-08 <br />Model Number. Install date <br />Installed onD Floor El Wall <br />Skimmer equalizer line(s) pipe size were found to be 1.5 inches Number of Skimmers: 1 <br />THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER <br />I declare that I hold an active California State Contractor license # 608182 with classification c53, 35 or a California State <br />Professional Engineer license # with qualified experience working on public swimming pools and that the information <br />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 <br />disciplinary action at the discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. <br />Robert R. Burkett Contractor/Engineer Name: Company Burkett's Pool Plastering, Inc. Name: <br />Company Address: P.O. Box 938 <br />Salida City: State: Ca Zip Code: 95368 <br />Contractor/Engineer Phone Number: Cell Phone Number 209 599-3317 <br />1701 Contractor/Engineer FAX Number: 209 599- Ern <br />Robert R. Burkett <br />n Contractor I Engineer name (PRINT) Cont-rjar / <br />09-08-10 <br />en'Thi (e.e ii- a(-m i(SIGNATCRE) Date <br />For a complete text of the law, visit: http://Info.sen .ca.gov/pub/09-10/b111/a sm/ab_1001 -1050/ab_1020_bil1_20091011_cha ptered. pdf <br />Re,set1: July 14, 2010