COMPLIANCE INFO_PRE 2020 - Laserfiche WebLink

Home Browse Search

APPROVED BY: DATE: Company Name: Burkett's Pool Plastering, Inc. state: Ca Zip Code: 95368 55202-2009 JOB: REPLACEMENT AB1020'S FOR RECALL California Department of Public Health Compliance Form Anti-Entrapment Devices and System. for Public Pod* and Spas OFricr USE ONLY Health and Safety Code Sections 116064.1 and 1160642 NOTE: Use one form for each wino or midticile IMMO under the some drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form la to be used to wilily compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and 1100642. Under Section 116064.2 (a) of the Health and Safety Code, effective January 1, 2010. the owner of a public ewirmning 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 arid Building Department for any necessary pion approval and permits prior to construction or remodel. Phase 2 IlIclatatmilism West Point Apartments : Spa Facility Name: Pool identification (If more than 1 pooltspe at site) Facility Address: 6465 N. West Lane Owner Name: Owners Phone Number: Owners Address City St. Zip Pool constructed on or after January 1, 2010?: ci Yes N No Hayward Recirculation Pianp Zr Pum13 Pentair Whisperflo H.P 1 akelModel R/S 1500 H.P 2 "—Moire/Model rther Pump: LF•alure Pump Make/Model MaktDrein tit/dudes All Suction °Wats Fitt:ant 91[Imeriar Eauslizer I-1111111 Al ORCFR101 Manufacturer of approved drain cover: 2-Aqua Stan l 0" round M deli NUfflo Wig onr. Install date 9-5-12 GPM rating: Floor 170 wail 170 Installed on oor Manufacturer of approved drain cover: Model Number Install date . GPM rating: Floor Well installed onElFloor 0 WM Main drain/Jet suction pipe size is _I inches. Check One: [2] Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plirnbed) El Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) 7 Single drain - Not unblockabie (one of the following Secondary devices required: safety vacuum release system, suction limiting vent I—I 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:modeupeN Numberinstall date Manufacturer of approved device: - . .. _..__ . Safety Vacuum release system bears the following performance standard markings: ID ATSM F2387 Li ASMEJANSI standard A 112.19.17 city Stockton st Ca 4: 95210 Skimmer Ecoallzer Linetal Aqua Star 10" round Manufacturer of approved suction filling GPM rating: GPM rating: Floor 166 wail 96 Skimmer equalizer line(a) pipe size we found to be 2 inches Number of Skimmers: 1 THE MIME HAS BEEN FIELD VERIFIED TO COPPLY WITH MANUFACTURER'S INSTALLATION RECASSEMENTS BY THEINSTALLER I declare that I hold an active California State Contractor license * 808182 with classification C53 or a California State _Professional Engineer license # with qualified experience working on public swimming pools and that the information provided above is true to the best of my knovAedge. I understand that If I Improperly certify this Information, I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health & Safely Code Section 116064.2. 10AVR101 9-5-12 Model Number: Install date Installed on nioor nWall Contractor/Engineer Name: Robert R. Burkett Company Address: P.O. Box 938 City: Salida Contractor/Engineer Phone Number 209 599-3317 Contractor/Engineer FAX Number 209 599-3317 Robert R. Burkett Q For a complete text of the law, visit httpllInfo.sen.ce.9ov/p1Jb109-10/bil Contractor/ Engineer' name (PRINT) ContreCtO name (S;l:-.3TURE) Date 10014060lab_1020_h111_2003101 i_chapteried.pdf 10-2-12 Cell Phone Number Email: Rwtiatt kilt 14, 2010