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APPROVED 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 Dump or multiple Pumps under the same suction fitting. THIS FORM IS INVALID IF ALL SECTIONS ARE NOT COMPLETED. This form is to be used to verify 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. She Information -f' Facility Name: 1�.//irh R�`MDP{r R4. Pool Idendfi d�o�(if more than 1 pool/spa et site): 0 pool Facility Address' _I f#O re (.�te< S f' City: L; St: C Zip: U Z!/-`y Owner Name: Owner's Phone Number. 2-09��'r(8-�'3Cj Owners Address City _St—Zip Pump IO omtation ❑Recirculation PurII' . ❑ Jet/Booster Pump Make/Model peg ,'r J.Nt'K��i W_b - S✓R3 H.Pj[ f Make/Model H.P 00ther Pump: �— D Feature Pump MakefModel H.P MakeWodel H.P WpI Drain I Suction Drain an suction ti - er t anki summer equalizer lines) 1 Manufacturer of approved suction fitting: a. Model Number: P Sall Install date �S'ao�D GPM rating: Floor 2TO Wall 2d0 Installed on S(Floor 0 Wall Manufacturer of approved suction fitting: Model Number: Install date GPM rating:Floor Wall Installed on D Floor ❑Wall Main drain/Jet suction pipe size is_____inches. Check One: D Dual main drain(s)(Minimum 3 ft.between covers, hydraulically balanced and symmetrically plumbed) Itto Single drain-Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) '1 Single drain-Not unblockable (one of the following secondary devices required, SVRS/Suction limiting vent I gravity drainage I auto pump shut-off/other approved device by enf rcement gency-)� � Type of secondary device installed�ir I Wert— - - Manufacturer of approved device: y : r' _ Model/Part Number. fV ILP SVRS bears the following performance standard markings! n ATSM F2387 VASME/ANSI standard A 112.19.17 Skimmer Euuslizer n efal �/ Manufacturer of approved auction fitting: NQ�tl Model Number: Install date GPM rating:GPM rating:Floor ;wall Installed on ❑Floor D Wall Skimmer equalizer trials)pipe size were found to be inches Number of Skimmers: ❑ Single equalizer line CI Skimmers are separately valved before pump and can be isolated. D Dual Skimmer equalizer line(s) ❑Skimmers are connected with single line to pump. THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLYWITH MANUFA INSTALLATION RE UIREME S BY THE INSTALLER I declare that I hold an active California State Contractor license# 'Z �. )6 I with classification or Calftmia 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 action at the discretion of the licensing authority In accordance with California Health&Safety Code Section 116064.2. 0 Contractor/Engineer Name: 2m 4.L Company Name: CompanyNj d�ress: City:iI ae h i X State:�`Zip code: D 0 Contractor/Engineer Phone Number. Cell Phone Number: q/ — 4w Contractor ngineer F Number: Email: r -l6-aofo Nntrackill,/Snaineer name(PRINT) Con a or ee ame(SIGNATURE) Date For a corn to text of the law,visit: ht ://info.sen.ca, ev/ ubl -1 illlasmlab 1001.1050/ab 1020 bill 20091Q11 cha tered. df a.tn2wo Si2:d6ed 82T0t`9b602T:01 ObTSL999% 0bTTL9S9T6:W0ud b2:ST OT02-9T-add