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APPROVED BY: California Department of Public Health OFFICE SE ONLY AB1020 Compliance Form F DATE: Anti -Entrapment Devices and Systems PR. for Public Pools and Spas SR: 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: FRIENDLY VILLAGE MHP Facility Address: 8600 WEST LANE Owner Name: MANAGED BY MONOLITH PARKS Owners Address Pool identification (if more than 1 poollspa at site): _City: STOCKTON St: CA Zip:95210 Pool constructed on or after January 1, 2010?: ❑ Yes O No Pump Information A Recirculation Pump Make/Model IRENTAIRINTELLIFLOVBF H PVARIABLI= Owner's Phone Number: City ❑ jet/ Booster Pump Make/Model Zip H,P ❑ Other Pump: ❑ Feature Pump Make/Model H.P Make/Model H.P Main Drain includes All Suction Outlets Except Skimmer Equalizer Lines Manufacturer of approved drain cover: AQUASTAR Model Number: A10RCFR101 Install date 211122 GPM rating: Floor770 Wall Installed on A Floor ❑ Wall Manufacturer of approved drain cover: Model Number: Install date GPM rating: Floor Wall Installed on ❑ Floor ❑ Wall Main drain/Jet suction pipe size is 2.5 inches. Check One: © Split 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 unbiockable (one of the following secondary devices required: safety vacuum release system, suction limiting vent system, gravity drainage system, auto pump shut-off system, or other equally or more effective system approved by enforcement agency) Type of secondary device installed: Install date Manufacturer of approved device: Model/Part Number. Safety vacuum release system bears the following performance standard markings: ` ATSM F2387 —_ ASMEIANSI standard A 112.19.17 Skimmer Equalizer Line(s) Manufacturer of approved suction fitting: NIA AUTOFILL Model Number: Install date GPM rating: GPM rating: Floor Wali Installed on ❑ Floor ❑ Wall Skimmer equalizer line(s) pipe size were found to be inches Number of Skimmers: THE ABOVE HAS BEEN FIELD VERIFIED TO COMPLY WITH MANUFACTURER'S INSTALLATION REQUIREMENTS BY THE INSTALLER I declare that I hold an active California State Contractor license # 701670 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 & Safety Code Section 116064.2. Contractor/Engineer Name. JOE PAGLUICA Company Address: 11363 PYRITES WAY City: GOLD RIVER ContractorlEngineer Phone Number: 916-63&7665 ContractorlEngineer FAX Number: JOE PAGLUICA Contractor I Engineer name (PRINT) For a complete text of the law, visit: http:llinfo.se Company Name: POOL TIME State: FA Zip Code: 95670 Cell hone Number: Emai RISTENPOOLTIME@GMAIL.COM 2115122 1GNATU RE) Date IIIIaBrNab_1p 11 10501ab_1020_ blil_20091011_chaptered.pdf Revised: July 14, 2010