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APPROVED BY: DATE: OFFICE USE ONLY JOB: 55202-2009 REPLACEMENT AB1020'S FOR work of 2009 California Department of Public Health Compliance Form Anti-Entrapment Devices and System for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for aalluates or muillpitt winos under dwearne drain over. AU- SECTIONS OF THIS FORM MUST BE COMPLETED. This form le to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and 1160542. 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 foliowing 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. Phase 1 Sit. Information Point Apartments Pool Facility Name: Pool identlItCallon (if rnore than .' pooUspe at site): Facility Address: 6465 N. West Lane car. Stockton Si: Ca zip: 95210 Owner Name: • Owner's Phone Number: Owners Address City St. Zip Pool constructed on or alter January 1. 20107: Yes 1 No inr2li R/S Hayward RftitililcUll(110,1 Pump 1500 H.P 1.5 ter Pump ake/Modei r_p 1 Boos 7takeiModei H.P ELCIAti.raite= UFeabire Pump _H.P.. Make/Model MULDrairinnekidis All Suction Ovtime Femmt Skimmer Emielker Lirefill 32CDFLFR101 Manufacturer of approved drain cover Channel Drain del NUMOtif . Install date 6-25-09 GPM rating: Floor 316 wait 208 Installed on icor 0 Wall Manufacturer of approved drain cover: Model Number install date GPM rating: Floor Wall installed otCfloor DWelt Mein drain/Jet suction pipe size n2 inches. Check ofn: Ei Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) 0 Sink) drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) n 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 Manufacaser of approved device: . - . .. ... ....__ . Model/Port Number Salety vacuum release system bears the following performance standard markings: 0 ATSM F2387 0 ASME/ANStitandard A112.19.17 litinwiter Ermaglier Uniksl Channel Drain 32CDFLFR101 6-25-09 Manufacturer of approved suction frtbrA: Modei Number. Install date GPM rating: GPM rating: Floor 316 wall 208 Installed on nioor DWall Skimmer equalizer line(a) pipe size were round to be 2 inches Number of SkImMers: 1 THE Alitaf-HAS BEEN HELD VERIFIED TO COMPLY TOTH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license i 608182 with classification 053 or a California State Professional Engineer license # with qualified experience working on public mvimming pools and that the information provided above is true to the best of my knovA•dge. I understand that If I Improperly certify this information, I shall be isubject 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: Surketre Pool Plastering, Inc. Company Address: P.O. Box 1338 City: Salida State: Ca Contractor/Engineer Phone Number. 209 599-3317 Cell Phone Number Contractor/Engineer FAX Number 209 599-3317 Emelt Robert R. Burkett A.. A t . .1.2,S.-411. 10-2-12 Contractor / Engineer name (PRINT) Contractor! name (SIG TURE) Date For a complete text of the law, visit telp:Mnfo.sen.cmgovipub108-10/bil . 1001-106010_1020_b111_200.101 l_shaptered.pdt Zip Code: 95368 RwANCt hey 14, 2010