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APPRO Bv: California Department of Public Health OFFICE 11i ONLY AB 1020 Compliance Form Health and Safety Code Section 116064.2 pa7E: NOTE: Use one form for each pump or multiple pumps under the same suction fitting. THIS FORM 15 INVALID IF ALL SECTIONS ARE NOT COMPLETED. this-form's to 3e 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 term within 30 days fallowing 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 Informati n Facility Name: t R a L P 4 pool Identificatioq(if more than 1 pool/spa at site) WlIi, � ,[ W Facility Addre : r S City: 1 ef'v St:C*�Zip: U`-715 Owner Name: Owner's Phone Number Owners Addrei a Cit, St _Zip Pfpmp Informal ion Rscirculatio r Pu ,/ Jet is ooatQr�Pump P MakelMotlel W f �S d H,P MakelModel Uh/t�Wl}t(!Y �� iL H.P� 00ther Pump ❑ Feature pump Make/Madel H.P Make/Model Hp gin in I S ction Drain iall suction fittipos other than skimmer u ti er lines Manufacturer of approved suction fitting: r Model Number:A S Q.L Install date GPM rating: Flox Wall 70 Installed on (Floor ❑ Wall Manufacturer of approved suction fitting: Model Number: Install date 3PM rating: Floor Watt Installed on El Floor 0 Wall Main drain/Jet suction pipe size is inches Check One: 4 Dual main drains)(Minimum 3 ft.between covers,hydraulically balanced and symmetrically plumbed) O Single drain-Unblockabie(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: SVR$/Suction limiting vent I gravity drainage I auto Pump shut-off/other approved device by enforcement agent Type f secondary device installed: ut Y. Manu cturer of approved device: Motlevpart Number: 5VRS bears the following performance standard markings: ❑ ATSM F2367 ❑ ASMEIANSI standard A 112.19.17 Skimmer Eau hilizer finals) Manufacturer f approved suction fitting: if Model Number. fl I -tot Install date GPM rating:G M rating:Floor_72- Wall 11- Installed on ❑Floor Qct Wall Skimmer equ izer line(s)pipe size were found to beLkw inches Number of Skimmers: I W Single aqua zer line o Skimmers are separately valved before pump and can be isolated. ❑ Dual Skimm ir equalizer line(s) ❑Skimmers are connected with single line to pump. THEA OVE HAS BEEN FIELD VERIFIED TO COMPLY TH MANUFACTUREn MANUFACTURER' INSTALLATION REQUIREMENTS BY THE INSTALLER 1 declare that I hold an active CalifOrhla State Contractor license# 7"161 with classification �'Ii_or California State Professional E igineer 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 ac on at the discretion of the licensing authority in accordance with California Health 8 Safety Code Section 116064.2. Contractor/Engineer Name: G O Company Name; Company d ess; a City: State; Zip Code: p 0 Contractor/Engineer Phone Number: Cell Phone Number, Contra "ctor/ n ineer F Number: Ems 1: � n ! n inner name(PRIN ) Con a r ee ame(SIGNATURE) Date For a cpm text of the law,visit. ht :!infc.5en.ca. o ub 09• Nl/asmlab 1001.10S0/2b 1020 bill 20091 11 the tered. df a..utZ•ear Sib:abed 8210t?96602Tr01 OKLL999% 06T1L9S9T6:w0JJ 92:9L 0T02-9T-add