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APPROVED BY: UAW: 55202-2009 REPLACEMENT AB1020'S FOR RECALL California Department of Public Health Compliance Form Anti-Entrapment Devices and Systems for Public Pools and Spas Health and Safety Code Sections 118064.1 and 116064.2 NOTE: Use one form for each pump or muilloie puma under the same drain cprmr. ALL SECTIONS OF THIS FORM MUST SE COMPLETED. This form le 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 construcbon 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. JOB: oFncE U_SE ONLY ANLInbansOsn Spa-Phase I Facility Name: West Point Apartments Pool identification (if more than 1 pool/spa at site): Facility Address: 6465 N. West Lane city: Stockton st: Ca Bp: 95210 Owner Name: Owen Phone Number. Owners Address City St. DP Pool constructed on or alter January 1, 20107: 0 Yes 1 No - IL. 00,1 eke/Model H.P.1 rnlitka/Model H.P tion Whi Purap sperlio Booster Pump Recircula Other Pump: Feature Pump aka/Model . _H.P Make/Model H.P Maki Drain OackrtieRAJILSoodenQupete *went fildrnnwir Ewan:sr Lineal 32CDFLFR101 6-25-09 Manufacturer of approved ctraln oDver. -Channel Drain del NUMMI. Install date GPM rating: Floor 316 Weil 208 Installed on loor CI Wall Manufacturer of approved drain cover: Model Number Install date GPM rating: Floor Wall Installed onuFloor []Wall Main drain/Jet suction pipe size is inches. Chock One: 0 Split main drain(s) (Minimum 3 It. between covers, hydraulically balanced and syrnmetrically plumbed) 0 Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) El Single drain - Not unblocitable (one of the following secondary devices required: Safety Va0JUM 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 perftxmance standard markings: D ATSM F2387 o ASME/ANSI standard A 112.19.17 Skimmer-Emmen= Unsisl NONE Manufacturer of approved suction titling: Model Number GPM rating: GPM rating: Floor Wall Installed on Floor DWall Skimmer equalizer line(e) pipe size were found to be inches Number of Skimmers: Install date THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY INITH MANUFACTURER'S PISTALLRTION REQUIREMENT‘py THE INSTALLER I declare that I hold an active California Stets Contractor license* 608182 with classification C53 or a California State Professional Engineer license # with qualified experience V II:Irking on pudic swimming pods and that the information provided above is true to the best of my knowledge. I understand that It I Improperly certify this information, I shall be subject to potential disciplinary action at the discretion of the kcensing authority in accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Name: Robert R. Burkett company Name: Burkett* Pool Plastering, Inc. Company Address: P.O. Box 938 City: Salida State: Ca Zip Code: 85388 Contractor/Engineer Phone Number 209 599-3317 Ceti Phone Number Contractor/Engineer FAX Number. 209 599-3317 Email: Robert R. Burkett 10-2-12 Contractor / Engineer name (PRINT) Contractor / E name (SIG URE) Date For a complete text of the law, visit http://lnrfe.sen.ca.gav/pub/08-101b 1001-1060fab 1020J411_20001011_chapterecl_pdt _ Rwrield July 14, 2010