Looking for a 1020 Form Templates? Download it for free!

Approved by:

San Bernardino County Environmental Health

OFFICE USE ONLY

385 N. Arrowhead Ave., San Bernardino CA 92415-0160

(909) 884-4056

FA #______________

______________________

Anti-Entrapment Devices and Systems for Public Pools and Spas

AB 1020 Compliance Form

PR #______________

Date__________________

Health and Safety Code Section 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 San Bernardino County Environmental Health and the local Building

Department for any necessary plan approval and permits prior to construction or remodel.

Site Information

Facility Name: ___________________________________________________ Pool Identification (if more than 1 pool/spa at site): _________________________

Facility Address: __________________________________________________City: _________________________________ St: _____ Zip: ________________

Owner’s Name: ________________________________________Owner’s Phone Number: _______________Email:____________________________________

Owner’s Address: _________________________________________________City: ______________________________St.: ________ Zip: _________________

 Yes

No

Pool constructed on or after January 1, 2010?

II.

Pump Information



 Recirculation Pump

 Jet / Booster Pump

Make/Model ______________________________________H.P____________ Make/Model ________________________________________H.P________

 Other Pump:

 Feature Pump

Make/Model ______________________________________H.P____________ Make/Model ________________________________________H.P________

III.

Main Drain (Includes All Suction Outlets Except Skimmer Equalizer Lines)

Manufacturer of approved drain cover: _____________________________________ Model Number: ____________________Install date: ___________________

Make/Model ______________________________________H.P__________ Make/Model ____________________________________________H.P________

 Floor  Wall

GPM rating: Floor_______________ Wall: ________________

Installed on

Manufacturer of approved drain cover: _____________________________________ Model Number: ____________________Install date: ___________________

 Floor

 Wall

GPM rating: Floor______________ Wall__________________

Installed on

Main drain/Jet suction pipe size is ______ inches.

Check One:

 Dual (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 -Unblockable (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: _____________________________________

 ATSM F2387

 ASME/ANSI standard A 112.19.17

Safety vacuum release system bears the following performance standard markings:

Date the main drain was split if it was not part of the original construction:_____________________________________________________________________

IV.

Skimmer Equalizer Line

_____________________________________________________________________________

Manufacturer of approved suction fitting: ____________________________________ Model Number: ________________________Install date ________________

 Floor

 Wall

GPM rating: GPM rating: Floor______________ Wall________________ Installed on

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 # _________________ with classification _________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 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: _______________________________________________ Company Name: _____________________________________________

Company Address: __________________________________________________________________________________________________________________

City: _________________________________________________________________________ State: __________________ Zip Code: ____________________

Contractor/Engineer Phone Number: ___________________________________ Cell Phone Number: ______________________________________________

Contractor/Engineer FAX Number: _________________________________Email: ______________________________________________________________

________________________________

___________________________________

_________________

Contractor / Engineer Name (PRINT)

Contractor / Engineer Name (SIGNATURE)

Date

For a complete text of the law, visit:

Rev 2/7/2011

Form Ab 1020 - Anti-Entrapment Devices And Systems For Public Pools And Spas Compliance Form

Related Articles

Related forms

Related Categories