HomeMy WebLinkAboutApplication 1 Amato Drive ^oW« dry 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: U'f-S t_4-U4-- µT 9C.V i W (W P50�.
ADDRESS IWT-0 17 �� S; lt% (4) P-90,i2- C-7
PHONE: 6 5 ���s h ��� EMAIL: s VeC-P— WC?Stkor S M,; � Cau9
OWNER/ASSOCIATION
REPRESENTATIVE: &A(SS, ✓0/�1 / aMQy P� �Cd �f �'� uI
r ,
ADDRESS: 3 +S Zua t/00n c4 CT O GO
PHONE EMAIL: 5tC
MANAGER(if different from owner):
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ADDRESS
PHONE NUMBER EMAIL:
POOL
OPERATOR:_ �ciJL—
ADDRESS 1G37 t-rk . lyc/ s, W(udsor C7- Obc) 7 1
PHONE NUMBER � � Z�l'I I���C EMAIL 1(1 Cg_ 5 `CIS L__es' IV , CC"—
FACILITY INFORMATION:
Check all that apply-
Indoor Pool � Outdoor Pool t' Wading Pool Whirlpool/Spa
Dates Pool is Open: From R0 Z U (_1 to
Pool Capacity.-
Pool Make-up Water Source: Public V Private
Disinfectant Used: Q-bL 1u�- !A,—
The undersigned agrees to comply with Section 19-13-11333b of the Connecticut Public Health Code:
Signature of Applicant Title f U Date
RECEIVED
'Please return completed registration form to the South Windsor Health Department Pool inspection requests must be Mydu@c82Mjl1.
prior to anticipated pool opening date.
SOUTH WINDSOR
HEALTH DEPT.