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Town of South Windsor — Health Department
�O a 1540 Sullivan Avenue, South Windsor, CT 06074
s Phone: 860-644-2511 ext. 250 Fax: 860-644-7280
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PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME: S�i'a &, 6Ae/d i171 I /)5-�',C-;u//
ADDRESS: /h i 11 PA,AI (,ter., ro S ,ifl, W i fv C T- &Eo 7 y
PHONE: S u S'Ld' -k85_
EMAIL:
OWNER/ASSOCIATION
REPRESENTATIVE: r,
ADDRESS: 5 y8 l�a/ r1C-� / �/yn/�kC ��(�✓ytu l'T OGD¢'lo
PHONE: �G S-L 2 d'�t'.f EMAIL: ,�l
MANAGER (if dill ent from owner): r/�
ADDRESS:
PHONE NUMBER: EMAIL:
POOL
OPERATOR:_ Sf-•.Y, a Poe, 1 S
ADDRESS 9/ I is F� a��k Ci r C < f i } d• u
PHONE NUMBER S 6 " 28 z- EMAIL
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool_Wading Pool Whirlpool/Spa
Dates Pool is Open: From 4� to
Pool Capacity: v .'
Pool Make-up Water Source: Public J`' Private
Disinfectant Used: C 4��-'K
The undersigned agrees to comply with Section 19-13-1333b of the Connecticut Public Health Code:
�i
Si nature of Applicant Title Date
RECEIVED
'Please return completed registration form to the South Windsor Health Department. Pool inspection requests must be AQulA Uels
prior to anticipated pool opening date.
SOUTH WINDSOR
HEALTH DEPT.