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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: NC 1TE: 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 tone is to e used to verity compliance with modifications pursuant to the new suction hazard prevention law. Under Section 1160642 of the Health and Sal y 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 rmits prior to construction or remodel. 4fte,Informatin { p Facility Name: T(A1 ' LDP R 2 L � Pool Identificatio (if more than 1 poollspa at site): tN Facility Addres�: r tEL City: I DIS St:_CA�.Zip:_ Ureter Name: Owner's Phone Number. _7-09-�'r1 Owners Address City St._Zip — I PMD Information (;PRecirculation P �L Jet 1 Boos r Pump Make/Model H.P3(M Make/Model __ QtQ, �f/boo _ d �H.P V OOther Pump 0 Feature Pump Make/Model H.P Make/Model H.p Main Drain I S ction Drain all auction fitti s other n skimmer o u Ozer linea Manufacturer o approved suction fitting: Model Number: Install date � '_ (Q 3PM rating: Flox r D D Wall Installed on y�Floor cl wall Manufacturer of approved suction fitting: Model Number Instep date 3PM rating: Flo r Wall Installed on 0 Floor 0 Wall Main draiNJet suction pipe size is inches. .heck One: ❑ Dual r iain drain(s)(Minimum 3 ft.between covers,hydraulically balanced and symmetrically plumbed) 0 Singlf drain-Unblockable(size and shape that a human body cannot sufficiently block to create a suction entrapment) 0 Singl drain-Not unbloekable (one of the following secondary devices required: SVRS/Suction limiting vent/gravity drainage/auto pump but-off/other approved device by enforcement agency) Type of secondary device installed: Manufacturer of approved device: ModellPad Number. SVRS bears the following performance standard markings: 0 ATSM F2387 4 ASMEIANSI standard A 112.1917 Skimmer Eau Mkyr line(s) Ap�� Manufacturer f approved suction fitting: nftimc e —Model Number, 0S Install date GPM rating:G 3M rating. Floorj f7D Wall Installed on ❑Floor 0 Wall Skimmer aqua iter line(s)pipe size were found to be - jnche5 Number Of Skimmers: Ot Single equa zer line 0 Skimmers are separately valved before pump and can be isolated. Q Dual Skimm Dr equalizer line(s) ❑Skimmers are connected with single line to pump. THEA OVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REGHIIREM--E—NrS BY,THE INSTALLER I declare that I hold an active California State Contractor license ii „]�'S 1 6 with dassification�L+ —or Califomia Stale 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 Ion at the discretion of the licensing authority in accordance with California Health&Safety Code Section 116064.2. Contractor/En ineer Name: iG O Company Name: Company Add ss: .3 t , City: State: Zip Code: Contractor/Engineer Phone Number: Cell Phone Number: Contractorl n ineer F Number: Emaj: nt o / n ineer name(PRIN ) Can or gi ee ame(SIGNATURE) Date For a Com t text of the law,visit. tlh:Ili fo.sel:.ca. ovt ub/09-1 illlasm/ab 10n9.905 f 1020 bit 20099 99 Cha tared. df Rey urmSCt� S/S:aced B2T0b9b602T:01 Ot�TTL999T6 0bTTL9S9T6:Woud S2:ST OT02-9T-add