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i APPROVE 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_PuM or multiple pumps under the same suction fitting. THIS FORM IS INVALID IF ALL SECTIONS ARE NOT COMPLETED. This form is to m used to verify compliance with modifications pursuant to the now suction hazard prevention law. Under Section 110054.2 of the Health and Safety Code,effective January 1, 2010,the owner of a public swimming pool shall file this forth 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 p rmits prior to construction or remodel. She Infomhati in { Facility Name: -}-w Lot R R CIU4 Pool ldentificatio (if more than t pooUspe at siteg QT i>OOIL POOLv FaciliyAddresi e S City: SC Zip: 9Lgy Owner Name: owner's Phone Number Owners Address Addre Ss City St. Zip ?ump Informal on QRRecimulationP ' 0 ❑ Jet I Booster Pump Make/ModelLj� D d H.P_ Make/Model H,P l�Otlter Pump f ❑ Feature Pump Make/ModelH P Make/Model H Main Oral n/SL ction orcin all auction 111 otherthen skimmer equalizer lines Manufacturer of approved suction fitting: M1 - Model Number.. Install date 3PM rating: FI r �( Wall Installed on ,kFloor 0 Wall rNaoufacturer of approved suction fitting; Or.A7r m ay " Model Number: date 3PM rating: Flo r :Zti Wall_ � Installed on O Floor R Wail Main drain/Jet suction pipe size is_�inches. Check One: O Dual i nain drains) (Minimum 3 ft. between covers. hydraulically balanced and symmetrically plumbed) O Singl drain-Unblockable(size and shape that a human body cannot sufficienty,block to create a suction entrapment) Single drain-Not unblookable (one of the following secondary devices required:SVRS/Suction limiting vent/gravity drainage I auto pump shut-oft/other approved device lo enf rcement a;7 cy) Type fsecondarydeviceinstalled: 'y. jnl,Y �4 "4IV" Manulacturer of approved device: 4lq4n& T ,.,� MadellPart Number:_DCII AU SVR bears the following performance standard markings. ❑ ATSM F23B7 ASMEIANSI standard A 112.19.17 Skimmer E u jilzer lines 9 Manufacturer f approved suction fitting: I=an O,J NL Model Number: Install date p GPM rating;G M rating:Floor `-.00 Wall a. Installed on ❑Floor g Wall r Skimmer equalizer line(s)pipe size were found to beinches Number of Skimmers;. d Single equalizer line ❑Skimmers are separately valved before pump and can be isolated. ❑ Dual Skimm r equalizer line(s) Skimmers are connected with single line to pump. THE ABQVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INST L.LATION REOUIREME S BY THE INSTALLER I declare that I hold an active California Slate Contractor license#_ 7,C l 6 j with classihcaton 41 or California State Professional Engineer license# ,with qualified experience wonting on public swimming pools and that the information provided abov is true to the best of my knowledge. I'm aware that improper certification of the above information shall be subject to potential disciplinary ac'on at the discretion of the licensi authority in accordance with California Health&Safety Code Section 116064.2. ContractadEn ineer Name: 1° 0 Company Name: / Company d ess; t City: 114 State: _Zip Code: 0 0 Contractor/Engineer Phone Number; f Cell Phone Number. Contractor/ n ineer F Number r Email. n a o / n ineer name(PRINT) Con is or g ee ame(SIGNATURE) Uate For a comp t text of the law,visit httm://into. jar ,g0Wou612L-A nUasm/ab 1001401501ab 1020 bili 20091011 chaptered ndf wr mnROt Si£kaspd 8£T0b96602T:01 06TT2_9S9T6 0bTTL9S956:w0JJ b2:ST 0502-91-NdU