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Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 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::)� -Dee,Sc. 74- ,��ZZ<
ADDRESS: /7r �� T)V'v'
PHONE: EMAIL:
OWNER/ASSOCIATION
REPRESENTATIVE: 1.1.le 5� y .L.� f�{� /—'S/. &
ADDRESS
PHONE: �'�. S�Z -2 i' EMAIL:
MANAGER(if different from owner):
ADDRESS
PHONE NUMBER EMAIL:
POOL
OPERATOR:
ADDRESS 6'3 )�hh l-1 Ac ! r (.'J� , s.• L'T <�� n 7 Y
PHONE NUMBER f6c, z 97 1926 EMAIL
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool y° Wading Pool Whirlpool/Spa
Dates Pool is Open: From to _ -,ale-4,_
Pool Capacity: 9�
Pool Make-up Water Source: Public Private
Disinfectant Used: G� fo ----
The undersigned agrees to comply with Section 19-13-B33b of the Connecticut Public Health Code:
Si ature of App'cant Title Date
RECEIVED
MAY 1 0 ZO17
"Please return completed registration form to the South Windsor Health Department. Pool inspection requests must be scheduledd 2 eeks
prior to anticipated pool opening date. SOUTH WIND SUK
HEALTH DEPT.