COMPLIANCE INFO_PRE 2020 - Laserfiche WebLink

Home Browse Search

APPROVED BY: DATE: JOB: 55202-2009 REPLACEMENT AB1020'S FOR RECALL California Department of Public Health Compliance Form Anti-Entrapment Devices end Systems for Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each ono OFFicE USE ONLY or mull& DURUM under !twain* drain cover. ALL SECTIONS OF THIS FORM MUST NE 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 CIVRIer of a public rorimming pool shall Me this form within 30 days following the cotyledon of conslruction or installation of and-entrapment devices or systems in swimming pools. Contact your local Environmental Health Department and Building Deparbnent for any necessity plan approval and permits prior to construction or remodel. Phase 3 Sits Information West Point Apartments Spa Facility Name: Pool identifkation (If more than 1 pool/spe at site): Faculty 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?: 0 Yes 0 No Pentair 11,• FA Recirculation Pump ake/modei Challenger H.P. 1.5 /st fBOOSt*fPUITlP Pentair Whisperflo 1 —diake/Mociel H.P LiFeetune Pump Make0Model H.P Other Pump: ke/Model Main Drain (Includes AS Suction OtItlels Extvot Skinwvlar EaLlagzar unl111 32CDFLFR101 Manufacturer of approved drain cover Channel Drain .M9,del ivurnoer. Install date 9-)-12 GPM rating: Floor 316 weo 208 Installed onialoor 0 Well Manufacturer of approved drain cover: MiAsi Number Install date GPM rating: Floor Wall installed or0Floor u Wall Main drain/Jet suction pipe size is 2 inches. Check One: p Split main drain(s) (Minimum 3 It_ between covers, hydraulically balanced and symmetrically plumbed) IZI Single drtiin - Unblookable (size and shape that a human body cannot sufficiently block to create a suction entraixnent) n Single drain - Not unblockable (one of the foilOwing 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 Manufacturer of approved device: - - - .. _____ .. ModeUPart Number Safety vacuum release system bears the following performance standard markings: 1:1 ATSM F2387 0 ASME/ANSI standard A 112.19.17 10AVR101 9-5-12 Model Number Install date Installed on Door [71 Wail THE ABOVE HAS BEEN HELD VERIFID yo comply yliTti MANUFACIVRERI pISTALLAT1ON REaummurrs BY THE INSTALLER I declare that I hold an active California State Contractor license* 608182 with classilicstion C53 or a California State Professional Engineer license a with qualified experience working on public swimming pools and that the information provided above is true to the best of my knowledge. I understand that If I Improperly certify this information, I shall be sut+ect to potential disciplinary action at the discretion of the licensing authority in accordance with California Health 8 Safety Code Section 118084.2. Contractor/Engineer Name: Robert R. Burkett company Name: Buriurtt's Pool Plastering, Inc. Company Address: P.0- Box 939 City: Salida State: Ca Zip Code: 95358 Contractor/Engineer Phone Number 209 599-3317 Cell Phone Number Contractor/Engineer FAX Number 209 599-3317 Robert R. Burkett 1 Cordractor / Engineer name (PRINT) Contractor! name (SIG URE) Date Fore complete text of the law, visit http://1nfo.sen.ca.gov/pubf09-1 _1001-1050‘ab 1020_bN1_20091011_chaptered.pof rtiMeset Ju/4, 14, 2010 Skimmerlduallzer Unite' Aqua Star 10" round Manufacturer of approved suction fitting: GPM rating: GPM rating: Floor 166 wag 96 Skimmer equalizer line(s) pipe size were found to be 2 inches Number of Skimmers: 1 Email: 10-2-12