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e-23-10; 10:46AM; ' + 3 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 Dumb 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 verity compliance with modifications pursuant to the new suction hazard prevention law. Under Section 118084.2 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 constructon or remodel. Site Information Facility Name: C Pool Identification(If more than t pool/spa at site): Facility Address: 2901 w. S ',n '28. City: 1S+0C..L+41N St: CA Zip: 15ZOI Owner Name: Owner's Phone Number: Owners Address City St_Zip Pump Information^ �jx Recirculation PurqR ❑ Jet/Booster Pump Make/Model s + (kms �0.�lRG�4SS3L H.P N.5 MakelMotlel H.P ❑Other Pump: ❑ Feature Pump Make/Model —H P— Make/Model KP Main Drain/Suction Drain fall suction fitiln s other than skinniper equalizer lines Manufacturer of approved suction fitting: a Model Number: SDRC Re,(b Install date GPM rating:Floor 2016 Wall ICi 2- installed on ATloor ❑ Wall Manufacturer of approved suction fitting: Model Number: Install date GPM rating:Floor Wall Installed on o Floor O Wall Main drain/Jet suction pipe size is_inches. Check One: ❑ Dual main drains)(Minimum 3 R between covers,hydraulically balanced and symmetrically plumbed) ❑ Single drain—Unblodkabte(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 I gravity drainage/auto pump shut-off/other approved device by enforcement agency) . Type of secondary device installed" �Gt-i r• L V - f— Manufacturerofapproveddevice: \1&r— S Model/PartNumber: 5V2-S1oAD� SVRS bears the following performance standard markings: ❑ MM F2387 A ASME/ANSI standard A 112.19.17 Skimmer Equalizer finals) Manufacturer of approved auction fitting: Model Number. Install date GPM rating:GPM rating:Floor ;Wall Installed on ❑Floor ❑ Wall Skimmer equalizer line(s)pipe size were found to be inches Number of Skimmers; ❑ Single equalizer line ❑Skimmers are separately valved before pump and can be isolated. ❑ Dual Skimmer equalizer Iine(s) ❑Skimmers are connected with single line to pump. THE ABOVE HAS SEEN FIELD VERIFIED TO COMPLY WITH MANuFACTuREFkm INSTALLATION REQUIREMENTS BY THE INSTALLER I decere that I hold an active California State Contractor license# 13"12.fjf3" with classification._C-52� r California 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 lin accordance with California Heallth&Safety Code Section 116064-2. Contractor/Engineer Name: .JI � �- 1`-'ICAf{f 1/�.7i Company Name: lt; �C. -�;sy2( Ckn�J cpn Ao L, Company Address: VR?-C- Un;Ve rti n \ Ui k— City. CLor% State: CA Zip Code: Comractor/Englineer Phone Number: 4A I q— (kZb Cell Phone Number. + Contractor/Engineer FAX Number. - fe i. V L CPA eb 0_61 . rOM Jti-,, A--. Mari 4 0_7/ Contractor/Engineer name(PRINT) Contra to ame(SIGNATURE) Date For a complete taut of the law,visit hHg://infosen.ca.povlpub108-t0lbilllasml L 9001-1060/ab 1020 bill 20091011 chaptered.pdf err vlarsom