HomeMy WebLinkAboutApplication 20 Summerhill Drive rKuvs
Town of South Windsor — Health Department
O�o 1540 Sullivan Avenue, South Windsor, CT 066074
Phone: 860-644-2511 ext. 250 Fax: 860-644-7280
PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME: PARKU►E0 So 0 T'H LoNb a g-)5 o c r q i o rQ
ADDRESS: `- od 5i;t�Mr=RHItL 1�R�vF
PHONE: EMAIL:
OWNER/ASSOCIATION
REPRESENTATIVE: PARK0(F_W Sooi►-t CoN7)t3 C10 H) F_51'FoRL� {ZEAL E5r4(-F ►Ylgl,�g6�
ADDRESS: 341 4APT-FORD 'TuczN P 1KC 0EP,0ot.3 Cr 106rjl-y
PHONE: -1,(o0 - 5 ZS -Z`p i S EMAIL:
MANAGER (if different from owner):
C�R^c�� Ro g r RTS
ADDRESS:
PHONE NUMBER: S4c) _6-2S -2%S,_ X `f`+ EMAIL: erA5 wfz5 a`Fo R brn T, Lon1 POOL L,
OPERATOR: 5AQ DL Poo
ADDRESS 'I I Prze5 rI aT P14i2 it C I 2 om IF }f=I FA 57- f4Ai2rFWLa cr c7ioX .,j
PHONE NUMBER -t 0'0-7 a-7' 009ib EMAIL
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool Wading Pool Whirlpool/Spa
Dates Pool is Open: From `m a 11 to
Pool Capacity: 5
Pool Make-up Water Source: Public Private
Disinfectant Used: ClAL4-"�
The undersigned agrees to comply with Section 19-13-B33b of the Connecticut Public Health Code:
Signature tf`Appl' Title
Date
RECEIVED
'Please return completed registration form to the South Windsor Health Department. Pool inspection requests mustfO,ht c6le6rr weeks
prior to anticipated pool opening date.
SOUTH WINDSOR
HEALTH DEPT.