HomeMy WebLinkAboutAmato Drive ,��►.� oy�� Town of South Windsor — Health Department
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1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
1530 Sullivan Ave., South Windsor, Cr 06074-Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME:
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OWNER/ASSOCIATION
REPRESENTATIVE: 41f: !J (
ADDRESS: , � ��rC�cC� It�(ctiP �i�t - ? .V erncin, C ) D(r6E
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MANAGER(if different from owner):
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PHONE NUMBER: CX'f.y'�K EMAIL: 5'CNeOC At.jx-jkCLcrA
POOL
OPERATOR: Tla�
ADDRESS SCIAAJOCI OLD Ll QEC-QLI
PHONE NUMBER6?(" 112i�o EMAI 2SiolZh tjjlOr _C LUJ
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool Wading Pool Whirlpool/Spa
Dates Pool is Open From JG to 01_��6
Pool Capacity
Pool Make-up Water Source: Public Private _
Disinfectant Used:
The undersigned agrees to comply with Section 19-13-1333b of the Connecticut Public Health Code:
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Siq ature of"Applicant Title r DW
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*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
Routine Inspection I)li door Pool
�, r �, Town of South Windsor—Health Department
r: 0 Re-inspection I Outdoor Pool
' 1540 Sullivan Avenue,S.Windsor,CT 06074 0 Complaint 0 Wading Pool
Phone: 860-337-6182 Fax: 860-644-1930 0 Other:_ 0 Whirlpool/Spa
`, I Public Swimming Pool Inspection Report
Name of Facility: WeS�iuC L" \i Inspection Date: qZ
Address: Phone.-
Items marked with an X indicate non-compliance with CT Public Health Code(Section 19-13-1333b). Violations must be corrected by the listed compliance date.
a-4 Life Saving Equipment b-12 Vacuuming
J Ring buoy <15" inner diameter, attached to
50ft length of%" line Pool vacuumed to maintain cleanliness
Life pole/shepard's crook with blunted ends, a b-13 Accessibility to Pool Area
Outdoor pools surrounded by barrier(>4ft)
J minimum of 12ft in length
b-1 Pool Construction / Outdoor pool entry gates self-closing and self-
/ Pool in good repair J latching
Pool access restricted when pool is closed
b-2 Supervisory Personnel
Knowledgeable pool supervisor onsite b-14 Lifeguards
List of personnel provided to Health Dept. J Warning signs if no lifeguard on duty(letters
>4" high)
b-4 Pool Water Clarity
6" secchi disk at pool bottom visible / Warning signs visible from all entry points in
pool area
b-5 Pool Water Disinfection b-15 First Aid Kit
Automatic Feeder Used Kit filled, ready for use, materials current
>0.8 mg/liter Free Chlorine Amer. Red Cross 24-unit first aid kit or equiv.
b-5, b-6 Test Kits
Emergency Telephone
f DPD Test Kit onsite (for disinfectant and pH) b-16
Telephone readily available in pool area
b-6 Pool Water pH
b-17 Signs
Value between 7.2 and 7.8
b-7 Records and Testing "All persons shall bathe with water and soap
before entering pool
/ Residual disinfectant & pH tested prior to daily "Anyone having a communicable disease shall
opening ✓ not use the pool"
Daily pool testing records kept "Spitting, or blowing the nose in the pool is
b-8 Decks, Dressing,Toilet&Shower Rooms ✓ prohibited"
Clean, good repair, well ventilated "Running, boisterous or rough play is
0.5%chlorine cleaning solution for floors ✓ prohibited"
Shower water 90—105 degrees F b-18 Emergency Communications
Adequate toilet facilities / Directions to nearest telephone and first-aid kit
b-9 Equipment rooms/areas&Equipment J posted at entrance
Maintained in good repair, clean/sanitary J Telephone numbers (print>.25") of police, fire,
Skimmers, gutters, strainer baskets clean and in hospital and EMS
J good repair b-19 Registration
Drain grates compliant / Name of owner or owner's agent, address and
b-10 Deck Equipment J location on file
/ Handrails provided on steps, step holes, and c-1 Depth Markers
ladders / Markers on rim at min and max depth and
Equipment properly secured points of slope change
b-11 Pool Chemical Storage Markers visible from pool deck and from within
Stored in a cool, dry, clean, well-ventilated area pool
Containers stored tightly closed
Public Swimming Pool Inspection Report
7
c-2 Lifeguard stands Comments:
►,jf k.ps Lifeguard stand raised at least 4ft Filter Type:
Lifeguard stand located pool side adjacent to
t J P- deep end Filter Size:
c-4 Sign
J "No diving is permitted off the deck into Flow Gauge (gpm):
shallow areas of the pool"
Additional Requirements for Public Spas: TO rate (vol./flowrate x 60):
e- Pool Water Disinfection Filtration rate (gpm/sf):
Free available chlorine residua 1.0 mg/liter
when spa in use Free Chlorine Total: 1,
e-2 Pool Water Tempera41not
ater temperatures exceed 104 pH: 1
de ees F
e-3 Depth arkers
Minimu V2m kers located on rim or
adjacen
e-4 Precautio Si s
"Elderly ersons nd those suffering from
Heart isease,Diabe 5, High or Low Blood
Pre ure, shall not en er the spa"
" nsupervised use by c ildren is prohibited"
'Do not use while under t e influence of
alcohol/drugs"
"Do not use alone"
" e (Observe a reasonable time limpreferably
less than 15 min.): long exposures ay result
in nausea, dizziness, or fainting"
e-5 Oils, Body Lotions, and Soaps
Oils, body lotions&soaps must be rem ved
prior to spa use
I
Pool Supervisor: r — 1L Date:
(Pn t Name)
Health Inspector: Title:
p 07�5
(Signature)
DATE OF COMPLIANCE: f\fl r>— Re-inspection Required: 0 YES EYNO
S Windsor-Api i 1 10 11