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INSTRUCTIONS FOR FILLING OUT THE AB 1020 COMPLIANCE FORM



Use one form for each pump or multiple pumps under the same drain cover.

For example, a spa with a

recirculation pump and a jet pump each with their own set of split drains that terminate under a different drain

cover will require two forms. However, two pumps with split drains that terminate under the same drain cover will

require only one form. A minimum of one form will be required for each pool and spa.



All sections of the form must be completed.



Print legibly.

Site Information

Facility name – name of facility or DBA (e.g. Elk Grove HOA, ABC Apartments).

Pool Identification – description of the pool which will identify it when there is more than one pool on the property.

(i.e:

club house pool, spa next to office, etc.)

C. Facility Address – address, city, state and zip code of the facility where the pool or pools are located.

D. Owner’s name – owner, home owner association or corporation name.

Owner’s address – address, city, state, zip, telephone number of the owner or home owner association.

Owner’s email address- electronic address where information can be received.

G. Indicate if the pool was constructed on or after January 1, 2010.

II.

Pump information

Indentify the type of pump that is connected to the drain. If two pumps terminate under one set of split drains (e.g. one side of a split

suction drain is used for both a recirculation pump and a jet pump), describe both pumps. For each pump, provide the make, model

number and horsepower. Remember; complete a separate compliance form if the additional pump is connected to a different drain

cover.

III. Main drain (Includes All Suction Outlets Except Skimmer Equalizer Lines)

Provide the manufacturer; make and model; and the date the drain cover was installed.

Provide the floor and wall flow rating in gallons per minute for the drain cover. Note: If there are two different drain covers (e.g. one on

the wall and one on the floor), there is space on the compliance form to complete drain cover information for each drain.

C. Indicate the size of the pipe terminating at the main drain or jet suction.

D. Check a box to indicate the configuration of the drain.

Dual (split) Main Drains - means there are two drains that are hydraulically balanced and symmetrically plumbed and are

separated by a distance of at least three feet in any dimension between the suction outlets.

Single Drain - Unblockable means there is one drain approved to be unblockable so that a human body cannot sufficiently

block it to create a suction hazard.

Single Drain – Not- Unblockable - means there is a single drain which can be sufficiently blocked by a human body to create a

suction hazard. This type of drain must be protected by an approved safety vacuum release system or other equally or more

effective system. Provide the type of device installed, manufacturer, model and indicate which type of performance standard is

marked on the device (ASTM F2387 or ASME/ANSI standard A112.19.17).

Provide the date the main drain was split if it was not part of the original pool construction.

IV. Skimmer Equalizer line(s)

Provide the manufacturer; make and model; and the date the drain cover was installed. Equalizer lines are typically installed

approximately 18 inches below the mouth of the skimmer in the sidewall of the swimming pool

Provide the floor and wall flow rating in gallons per minute for the drain cover. Note: If there are two different drain covers (e.g. one on

the wall and one on the floor), there is space on the form to complete drain cover information for each drain.

C. Indicate the size of the skimmer equalizer line pipe.

D. Indicate the number of skimmers.

Contractor’s Certification Section

Enter a valid California State Contractor’s license number.

Enter the Contractor’s license classification (i.e. C53, C36 “A”,C61/D35 “A”)

C. Enter the California State Professional Engineer’s license number, if applicable.

D. Enter the Contractor’s / Engineer’s name and the company they are working for.

Enter the company address, city, state, zip code, telephone number, cell phone number, fax number and email for the Contractor /

Engineer.

Print the name of the Contractor / Engineer.

G. The Contractor/Engineer must sign the form.

H. Enter the date the form was signed.

Return the completed form to:

San Bernardino County Environmental Health

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

For more information, please see our website at sbcounty.gov/ehlus or call (909) 884-4056

02/07/2011:INSTRUCTIONS FOR AB1020 COMPLIANCE FORM final version updated Feb 7 2011

Form Ab 1020 - Anti-Entrapment Devices And Systems For Public Pools And Spas Compliance Form Page 2

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