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APPROVED BY: DATE: California Department of Public Health OFFICE USE ONLY AB 1020 Compliance Form Health and Safety Code Section 116064.2 NOTE: 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 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. Site Information - Facility Name: � I- C V -NC -J r2 -\/Ry J / Pool Identification (if more than 1 pool/spa at site): N / P, Facility Address: 2-701 0'±1 City: V a Maki S St: CC _ Zip: 9 S � P.5 _.2.-•t� Owner Name: L`>o i S 74 —rVI a S Owner's, Phone Number: - 3 Owners Address 1'-0 • ( A '302- Cityy.A4%rt A` St. CP' Zip ClS 5 �l Pump Information NFecirculationump NOA\e)�H.P ❑ Jet / Booster Pump Make/Model tiuWO�f Make/Model H.P ❑Other Pump: 40❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain /Suction Drain all suction fittin s other than skimmer a ualizer lines ��T �2— dV - ✓-Z Manufacturer of approved suction fitting: a t +a •Model Number: SDX �2+fo Install date/ GPM rating: Floor Z.(Dr-D CuOM Wall_ 1,':A2 Cil% M I stalled on MFloor ❑ Wall Manufacturer of approved suction fitting: Model Number: stall date GPM rating: Floor I(® Wall Installed on ❑ Floor XWall Main drain/Jet suction pipe size is inches. Check One: )( Dual main drain(s) (Minimum 3 ft. between covers, hydraulically balanced and symmetrically plumbed) ❑ Single drain - Unblockable (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 / Suction limiting vent / gravity drainage / auto pump shut-off/ other approved device by enforcement agency) Type of secondary device installed: Manufacturer of approved device: Model/Part Number: SVRS bears the following performance standard markings: ❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer Equalizer line(s) Manufacturer of approved suction fitting: •AaJaotsi LxT Model Number: V W16AVV (z6 kc Install date GPM rating: GPM rating: Floor no Wall i'J Installed on ❑ Floor I. Wall Skimmer equalizer line(s) pipe size were found to be inches Number of Skimmers: 1 )KSingle equalizer line 0(t- ❑ Skimmers are separately valved before pump and can be isolated. ❑ Dual Skimmer equalizer line(s) 0_A6t o Skimmers are connected with single line to pump. I declare that I hold an active California State Contractor license # R72'A 6 q with classification CS -3 or 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 (Nauthority in accordance with California Health & Safety Code Section 116064.2.`` CC __ Contractor/Engineer Name: yc^ A , 0JASL9Y Company Name: _ Agj,-r-6C � T.a k z: 1 JP�, r✓ Company Address: 113 2 (o n ; ,l ¢ r k D / City: It, knC L +0 r- State: C -A Zip Code: 2A (4 Contractor/Engineer Phone Number: 2 -OCA - 4104 - k &I -f- Cell Phone Number: US - `l l k IS Lb Contractor/Engineer FAX Number:` ?" - -L,3 LA - ILO 1�, LA Fkiaii �I uov. A e% cv, i -e 4 - ,_ RDA ca^A Contractor/ Engineer name (PRINT) For a complete text of the law, visit: http://info.sen.ca Rev III V2010 name (SIGNATURE) rLk Date