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JOB: APPROVED DV: DATE: OFFICE USE ONLY OPIAL..7 NOTE: Use one form for each wino or multiple pumps un • a drain cover. ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compilsnce with [nodificaliorm 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 warming 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 remodel. Ustinfomem Facility Name: Facility Address: Owner Name: Owners Address City St. Zip Pool constructed on or after January 1, 20107: 0 Yes II No Health and Safety Code Sections 116064.1 and 11 California Department of Public Health Corn pliance Form Anti-Entrapment Devices and Systems for Public Pools and Spas Q,5-11 Pool Identification (if more than 1 pool/spa at site): City: St Owner's Phone Number: P I Rocircuiatioq.puinp_ 41,45 H.P1111-4 aka/Model remit' 111104. H P 1_1Q:fel/Model PuNr.11140. 11 H.P Festure Pump Make/Model H.P Other Pump: ake/Mode Main Din (Includes All Suction Oudets F_xeiset Skimmer Enualteer Linte Manufacturer of approved drain cover: A 1 Model 1,1 UITILler .V1 co tligk)lklnstall date GPM rating: Floor Vt. Wall 1,4 Installed on I:Kfloor 0 Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall installed onnFloor 0 Wali Main drain/Jet suction pipe size is incries. Check One: ri Split main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) Ni. Single drain - Unblockable (size and shape that a human body cannot sufficiently block to create a suction entrapment) ri Single drain - Not unblockabie (one of the foilOwing secondary devices required: safety vacuum release system, suction limiting vent 1---J 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 performance standard markings: iD ATSM F2387 o ASME/ANS1 t ti A112.19.1l Skimmer Eauslinr Uneist Manufacturer of approved suction fitting: 'hike, 4.1.._ Model Number 10 )141%)(kNE Install date GPM rating: GPM rating: Floor 16(3 Wall 16 Installed on Door Wall Skimmer equalizer line(s) pipe size were found to be 121 inches Number of Skimmers: THE ABOVE HAS BEEN DELO VERIFIED TO COMPLY WITH MANUFACDARER'S INSTALLATION REQUIREMENAPY TIE INSTAljal I declare that I hold an active California State Contractor license* 608182 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. I understand that if I Improperly certify this information, I shell be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health & Safety Code Section 116064.2. 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 Contractor/Engineer Phone Number 209 599-3317 Cell Phone Number. Contractor/Engineer FAX Number: 209 599-3317 Email: Robert R. Burkett Contractor / Engineer name (PRINT) Contractor / Engineer name (SIGNATURE) Date For a complete text of the law, visit istbrinrdosen.ca.govipubi09-10/bildesmfeb_1001-10501ab_1020_bill_20091011.shaptered.pdt Reyturcl: July 'A, 2C710