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APPROVED BY: California Department of Public Health OFFICE USE ONLY AB 1020 Compliance Form Anti -Entrapment Devices and Systems DATE: For Public Pools and Spas Health and Safety Code Sections 116064.1 and 116064.2 NOTE: Use one form for each pump or multiple pumps under the same drain cover ALL SECTIONS OF THIS FORM MUST BE COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new Health and Safety Code sections 116064.1 and 116064.2. Under Section 116064.2 (a) 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 the completion of construction or installation of anti -entrapment devices or systems in swimming pools. 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: Facility Address Owner Name: Owner Address, Lincoln High School 6844 Alexandria Place Lincoln USD 1900 Swain Road Pool construction on or after January 1, 2010? ❑ Yes ® No Pump Information ® Recirculation Pump Make I Model: Preferred Pump 5RB85688 H.P. 15 ❑ Other Pump Make I Model: H.P. Main Drain (Includes all suction outlets except skimmer equalizer lines) Manufacturer of Approved Drain Cover: Hayward 18x18 GPM rating: Floor: 1000 Wall: Manufacturer of Approved Drain Cover: GPM rating: Floor: _ Main Drain(s) Sump Depth is 22 inches Identification Pool (if more than 1 pool/spa at site): City: Stockton Owner's Phone Number: 209-608-2336 City: Stockton ❑ Jet I Booster Pump Make I Model: ❑ Feature Pump Make I Model: Model Number: RSUN18HPHR101 Life Exp.: 5 years Installed on Model Number: pool St: CA Zip: 95207 St: CA Zip: 95207 Ra, H.P. Install Date: 4/14/17 ® Floor ❑ Wall Install Date: Wall: Life Exp.: years Installed on ❑ Floor ❑ Wall Main drain I jet suction pipe is 8 inches Check One: ® Split main drain(s) (minimum 3 feet 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: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pump shutoff system, or other equally or more effective system approved by enforcement agency). Type of secondary device installed: Install Date: Manufacturer of approved device: Model I Part Number: Safety vacuum release system bears the following performance standard markings: ❑ ATSM F2387 ❑ ASME/ANSI standard A 112.19.17 Skimmer Equalizer Lines) Manufacturer of Approved Suction Fitting: n/a GPM rating: Floor: Skimmer equalizer line(s) pipe size was found to be Model Number: Life Exp.: years inches Skimmer equalizer line(s) sump depth is Install Dale: Installed on ❑ Floor ❑ Wall inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTLLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license # 930970 with classification C53 or a 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 understand that if I improperly certify this information, I shall be subject to potential disciplinary action at the discretion of the licensing authority in accordance with California Health 8 Safety Code Section 116064.2. Contractor/Engineer Name: Sean J. Senior, President Company Name: National Aquatic Services, Inc. Company Address: PO Box 2168 City: Brentwood State: CA Zip Code: 94513 Contractor/Engineer Phone Number: Contractor/Engineer Fax Number. Sean J. Senior, President Contractor/Engineer Name (PRINT) For a complete text of the law, visit: Cell Phone Number: (925) 383-7923 Email: doreen@naspools.com 4/21/17 (SIGNATURE) , Date -A