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APPROVED BY: DATE: L<IT 84)cet" Pump Pentair Challenger akei/Model ij Feature Pump _H.P. Make/Model .1L. 00.1 H.P 1 '5 Recirculation Pump ace/Model _ . Other Pump: ake/Modei JOB: -55202-2009 REPLACEMENT AB1020'S FOR RECALL California Department of Public Health Compliance Form And-Enirapment Devices and Systems for Public Pods and Spas Health and Safety Code Sections 116064.1 and 118084.2 MOTE: Use one form for each Immo or muttlloie Dome under the sone drain cover. ALL seCT1ON5 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 reinodeL Phase I AttLinkandel ut 7 vv est Point Apartments Spa-Booster Facility Name: Pool Identification (if more than 1 pool/spa at site): Facility Address: 6465 N. West Lane city. Stockton st: Ca ZIp: 95210 Owner Name: Owner's Phone Number. Owners Address City St. Zip Pool constructed on or after January 1,2010?: Ei Yes 1 No OFFICE USE CIKY Main Drain Onciudee Ali Bodkin Oullefs Exceint Skimmer Enuafter unlill 10AVR101 Install date Manufacturer of approved drain cover: Aq 1.13 Stan l 0" round del Nun-weir. 9-5-12 GPM rating: Floor 166 mil 96 installed on low 0 Wall Manufacturer of approved drain cover: Ael Number: Install date GPM rating! Floor Wall Installed onloor U Waif Main drain/Jet suction pipe size is 2 inches. Check One: al Split main drain(s) (Minimum 3 R. between covers, hydraulically balanced end symmetrically plumbed) Single drain— Unblockable (size arid shape that a human body cannot sufficiently block to Create a suction entrapment) 1 1 Single drain — Not unblockable (one of the following secondary devices required: safety yawn 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/Pert Number: Safety vacuum release system bears the following performance standard markings; ci ATSM F2387 o ASME/ANSI standard A 112.19.17 Skimmer &waltzer Unifial Manufacturer of approved suction fitting: Model Number install date GPM rating: GPM rating: Floor Wail Installed on Dloor FlWall Skimmer equalizer line(e) pipe size were found to be inch's* Number of Sldrnmers: lughsovE HAS BEEN HELD XERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY_ThE OBITALIJER I declare that I hold an active California State Contractor license a 808182 with classification C53 or a California State Professional Engineer license # with qualified experience working on public swimming pods and that the information provided above Is tnie to the best of my knowledge. I understand that if I Improperly certify this lifkili istiori, I shall be subject to potential disciplinary action at the discretion of the licensing authority_in accordance with California Health & Safety Code Section 116084.2. Contractor/Engineer Name: Robert R. Burkett company Name; Burkette Pool Plastering, Inc. Company Address: P.O. Box 938 City: Salida State: Ca Zip code: 95358 Contractor/Engineer Phone Number 209 599-3317 Cell Phone Number Contractor/Engineer FAX Number 209 599-3317 Email: Robert R. Burkett --\$6161Ontroterf) 10-2-12 Contractor / Engineer name (F'RINT) nglneer name Date For a complete text of the law, visit htlp://Irrfo.sen.ca.gov/pub109-10113111/earefeb 1001-1060fab 1020_bIlf_20091011_chaptered.pdf 144h4sat .14/.1 14. 2010