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APPROVED BY: California Department of Public Health OFFICE USE ONLY AB 1020 Compliance Form Anti-Entrapment Devices and Systems DATE: For Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each pump or multiple pumps under the same drain cover. ALL SECTIONS 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 remodel. Site Information Facility Name: Franklin High School Identification Pool('If more than 1 pool/spa at site): Pool Facility Address: 300 North Gertrude City: Stockton St: CA Zip: 95205 Owner Name: Stockton Unified School District Owner's Phone Number. 29-933-7095 Owner Address: 1932 EI Pinal Drive City: Stockton St: CA Zip: 95205 Pool construction on or after January 1,2010? ❑ Yes ® No Pump Information 0 Recirculation Pump ❑ Jet/Booster Pump Make l Model: Pentair CMK H.P. 10 Make/Model: H.P. ❑ Other Pump ❑ Feature Pump Make/Model: H.P. Make/Model: H.P. Main Drain(Includes all suction outlets except skimmer equalizer lines) Manufacturer of Approved Drain Cover: Aquastar18X18 Model Number: WAV18101 Install Date: 9/15/10 GPM rating: Floor: 628 Wall: Installed on ® Floor ❑ Wall Manufacturer of Approved Drain Cover: Aquastar18X18 Model Number: WAV18101 Install Date: 9/15/10 GPM rating: Floor: 628 Wall: Installed on ® Floor ❑ Wall Main drain/jet suction pipe is 6 inches Check One: ® Split main drain(s)(minimum 3 feet between covers,hydraulically balanced and symmetrically plumbed). ❑ Single drain—Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment). ❑ 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: Install Date: Manufacturer of approved device: Model/Part Number: Safety vacuum release system bears the following performance standard ❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 markings: Skimmer Equalizer Line(s) Manufacturer of Approved Suction Fitting: Aquastar flinch EQ Cover Model Number: R4RND101 Install Date: 9/15110 GPM rating: Floor: Wall: 72 Installed on ❑ Floor ❑ Wall Skimmer equalizer line(s)pipe size were found to be: 2 inches Number of Skimmers: 8 THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTLLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active Califomia State Contractor license#930970 with clas0fication C53 or a California Slate Professional Engineer license# with qualified experience working on public swimming pools and that the information prq'vided above is true to the best of my knowledge. I understand that if I improperly certify this information,I shall be subject to potential disciplinary action at the discfetion of the licensing authority in accordance with California Health&Safety Code Section 116064.2. c Contractor/Engineer Name: Sean J.Senior a Company Name: National Aquatics Services Company Address: i'0 Box 2168 A:- City: Brentwood .m ..: State: CA Tip Code: 94513 Contractor/Engineer Phone Number. (925)513-9025 Cell Phone Number: X925)383-7923 Contractor/Engineer Fax Number: I925 5134941 Email: doreen@naspools.com Sean J.Senior f" 9/30110 Contractor/Engineer Name(PRINT) actor/Engineer Name(SIGNATURE) Date Foraoarnpleteteadofthelaw,visit: http:/rinfo.sen.ca.gov/pub/09-10/bilUasmhb 1001.1050/ab-1020—bill_20091g11_chaptered.pdf