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APPROD BY:' California Department of Public Health OFFICE USE ONLY AB 1020 Compliance Form Health and Safety Code Section 116064.2 DATE: NOTE: Use one form for each pump or multiple pumps under the same suction fitting. THIS FORM IS INVALID IF ALL SECTIONS ARE NOT COMPLETED. This form is tobe used to verity compliance with modifications pursuant to the new suction hazard prevention law, Under Section 116064.2 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 completion of suction hazard prevention modifications. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information ' I1 Q p Facility Name: 7tr- I Mot "d (, V Pool mentifiratio (if more than 1 poollspa at site): 0�OOIL p9q Facility Addis s�: u S City: !Mla' St: c0q, Zip. J 2ZVD Owner Name: Owner's Phone Number �Tw Owners Addre s City SL_Zip Pump inform" on Allhicirculatio P m I i ❑ Jet I Booster Pump Make/Model DSVnH.P VAMUrMake1lilloidel H.P (Other Pump:_ ( ❑ Feature Pump Make/Modal .P Make/Model H.P Main Drain/S ction Drain all suction fittings other than skimmer a ualizer lin Manufacturer c approved suction fitting: Model Number.pQLiC444—Install date n -, (p uPM a rating: Flo r haIva Installed on kFloor ❑ Wall Manufacturer o approved suction fitting: Oi.('�G M-0dyr Model Number:fAe, nstall date .'4 (0 GPM rating: FI '�Q b Wall 'l-0 d Installed on o Floor "all Main drain/Jet suction pipe size is Z,, inches. heck One: O Dual i ain drain(s)(Minimum 3 ft, between covers,hydraulically balanced and symmetrically plumbed) D Singl 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:SVRS I Suction limiting vent/gravity drainage I auto pump but-off/other approved device b enf rcement a ency) Typo (secontlary device installed: I�'q j11 lug ,:!V I V VJ Manuracturer of approved device:—&-wil 2111, I _ ModeVPart Number: .Cts Jl. P /IiC SVRS bears the following performance standard markings: ❑ ATSM F2387 ASMEIANSI standard A 112.19. 7 Skimmer Egu6flzer line(s) Manufacturer if approved suction fitting: ��i�xy{ Model Number UInstall date Y-14-10(0 GPM rating:GDM rating: Floor �d0 ;Wall_ 1A6J Installed on ❑Floor k Wall Skimmer aqua izer line(s)pipe size were found to be—inches Number of Skimmers:—,_ ❑ Single equal 2er line o Skimmers are separately valved before pump and can be isolated. ❑ Dual Skimm ar equalizer line(s) 16 Skimmers are connected with single line to pump. THEA OVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION RE UIREMEN S BY THE INST LLER I declare that I hold an active California State Contractor license# 7 KS 16 with classification EC, or Califomia 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'm aware that improper certification of the above information shall be subject to potential disciplinary a 'on at the discretion of the licensing authority in accordance with California Health&!Safety Code Section 116064,2. Contractor/Engineer Name: e 0 Company Name: L'P.�C`U �Ad PA,4 rf Company ds; City, 6 State:—A °L Zip Co/de, �� b Contractor/En lull®r Phone Number: r Cell Phone Number:_ 9 ��/ b- (0a ) lues!F Number: . . r Email, E Z,010[a oracoI n ineer name(PRINTCon a or gaa ame(SIGNATURE) DateFteM ofthe law,visit: 1001 / '1 a tared. df s.v+nvzo+ 9,ti:aced 8£T0t79t7602T:o1 Ot7TTISS9T6 0tTTL9S9T6:al0ud L£:80 0502-82-Jdu