HomeMy WebLinkAboutApplication 50 Andrews Way Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, Cr 06074- Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074-Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME:_ / ,•— O Cv= r r<< G..�t//L
ADDRESS: Sv i O(a'24-/
PHONE:_ 9Za-6VV- Zyzy EMAIL
OWNER/ASSOCIATION!r
REPRESENTATIVE:
ADDRESS
PHONE EMAIL:1�q,! ,, / Ci' c'.�L.� C ,�.�i.. 14_� ,
MANAGER(if different from owner):
ADDRESS
PHONE NUMBER: EMAIL:
POOL
OPERATOR: .1 f�"r�c�.� (� c'...-�._ L--� v r,�/�.o •G�..--` ( 1 � � ,�.� L'�.. ( c...�
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ADDRESS tip' /in�/,.+.� i Sc•-t,n. r✓ .d.�o� C'
PHONE NUMBER _kGO EMAIL lc�y .l_„�. C - 1•—(.t' �. . I., . ,.
FACILITY INFORMATION:
Check all that apply: /
Indoor Pool Outdoor Pool Wading Pool Whirlpool/Spa
Dates Pool is Open: I r cam ? to 30 5,,
Pool Capacity: va/w �-iin 4w 4 T leg-? 5a4r'-
Pool Make-up Water Source: Public ✓ Private
Disinfectant Used: h(c ,-. g i �� 5 ,, /. ._�
The undersigned agrees to comply with Section 19-13-1333b of the Connecticut Public Health Code:
or-
Signature Applicant Title Date
"Please return completed registration form to the South Windsor Health Department. Pool inspection requests must be scheduled 2 weeks
prior to anticipated pool opening date.
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