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APPROVED BY: DATE: JOB: 55202-2009 REPLACEMENT AB1020'S FOR work of 2009 California Department of Public Hearth Compliance Form And-Entrapment Devices and %mews for Public Pools and Spas Hearth and Safety Code Sections 116064.1 and 116084.2 NOTE; Use one form for ourng or multiple Dumps under the Dente drain paver. AU. SECTIONS OF THIS FORM MUST SE COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new Width and Safety Code sections 116064.1 and 1160642. Under Section 1160642 (a) of the Health and Safety Cod*, @Rosen 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 mainlining pools. Contact your local Environmental Health Department and Building Department for any necessary pion approval and perrniM prior to construction or remodel. _Phase 2 Altildsgoassi West Point Apartments Facility Name: Pool klendfIcatton (If more than 1 pooVspa at site): Pool Facility Address: 6465 N. West Lane city: Stockton st Ca zip: 95210 Owner Name: Owners Phone Number: Owners Address City St. Zip Pool constructed on or after January 1.2010?: 0 Yes II No I 1 . • UV-ILL _ l!..!il R/S Hayward Recirculation 1500 Punsp 'mist / Booster Puna, ake/Model H.P 1.5 r _., aka/Moder Li H.P terature Pump _H.P. Make/Model H.P tfialinDralas (Includes Al Stsceon Oulhols, Except Skimmer &waltzer unftal 32CDFLFR1 01 install date 6-25-09 Manufacturer of approved drain cover, t, hannel Drain del truinutir. GPM rating: Floor 316 watt 208 Installed on ioor 0 Wall Manufacturer of approved drain cover: Model Number Install date GPM rating: Floor Wall Installed orCVloor El Wall Main drain/Jet suction pipe size is 2 inches. Check One: Ei Split main drain(s) (Minimum 3 ft. between COWL hydraulically balanced and symmetrically plurnbed) 21 Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a Suction entrapMent) El []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 Initial! date Manufacturer of approved device: - - .- .. ___ Model/Part Number -Safety vacuum release system bears the following performance standard markings: cl ATSM F2387 0 ASME/ANSI -standard A-112.19.17 OFFICE USE ORLY Other Pump: akeiModer §kimmier Etrualizer Unets1 Aqua Star 4" Hockey Pu model Number 4HP101 manufacture( or apcnved suction fitting: (3ni rating: GPM rating: Flocr 56 waq 56 Skimmer equalizer line(s) pipe size were found to be 1.5 inches Number of Skimmers: 2 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MA4UFACIURER3iNSTALLATION gg9UI1EMENTILey THE INSTALLER I dedare 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 knowledge. 1 unCleratand that if I Improperly certify this information, I shall be sut4ect to potential disciplinary action at the discretion of the licensing authority in accordance with California Health & Safety Code Section 118084.2. Contractor/Engineer Name: Robert R. Burkett Company Name: Burkett's Pool Plastering, Inc. Company Address: P.O. Box 938 City: Salida State: Ca Zip Code: 95368 ContractoriEngineer Phone Number 209 599-3317 COI Phone Number Contractor/Engineer FAX Number 209 599-3317 Email: Robert R. Burkett Install date 6-25-09 inteled On Door 7J Wail 10-2-12 Contractor / Engneer name (PRINT) Contractor / E name (SIGNA RE) Date For a complete text of the law, visit httplfinfo.a•n.ca.govtpubt00-10141111essnlab_1001-1050lab_1020_b111_200111011_chaptenod.pd1 Ftritsect Afri 14, 2010