HomeMy WebLinkAboutSummer Hill Drive Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
p= _ 1530 Sullivan Ave., South Windsor, CT 06074- Office Address
� = Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
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PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME:PPL4 t,.t 5-C-AA ecv�d0(Off ,1A114 6Cex I- C) nC
ADDRESS: L-314,rniyl( i�I�n tiIIQ f �� �5 � a {jZ
PHONE:_ � Cep EMAIL:
OWNER/ASSOCIATION
REPRESENTATIVE: Ct)(Yt, "
ADDRESS: VPUhU
PHONE: rY�- �t-I(,EMAIL: I lS��nlaa rn. ,fie Runt+
MANAGER(if different from owner):
ADDRESS:
PHONE NUMBER: EMAIL:
POOL
OPERATOR: sc,0f)` C�
ADDRESS -
PHONE NUMBER Rlnn �g O I `, EMAIL hccmc un t�L .�/�4oi;kosS- am
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool L' Wading Pool Whirlpool/Spa
Dates Pool is Open: From to ' 1 c)� `l
v� � �nl
Pool Capacity �d C `k,
Pool Make-up Water Source: Public Private
Disinfectant Used: c4Ylt _ LhA
The undersigned agrees to comply with Section 19-13-B33b of the Connecticut Public Health Code:
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SignAtumXVApplicabt Title U Date
"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.
„wdt'00r` N Ooutine Inspection 0 Indoor Pool
r `'� Town of South Windsor-Health Department A Re-inspection A Outdoor Pool
1540 Sullivan Avenue,S.Windsor,CT 06074
0 Complaint 0 Wading Pool
Phone: 860-337-6182 Fax: 860-644-1930 A Other: 0 Whirlpool/Spa
Public Swimming Pool Inspection Report
Name of Facility: �(An -U�L�w Sbs��'�\ Inspection Date: 5I7 Z�I $
Address: 10L 1� �/ Phone:
Items marked with an X indicate non-compliance with CT Public Health Code(Section 19-13-633b). Violations must be corrected by the listed compliance date.
a-4 Life Saving Equipment b-12 Vacuuming
/ Ring buoy <15” inner diameter, attached to ✓
50ft length of%" line Pool vacuumed to maintain cleanliness
J b-13 Accessibility to Pool Area
Life pole/shepard's crook with blunted ends, a
Outdoor pools surrounded by barrier(>4ft)
minimum of 12ft in length
b-1 Pool Construction Outdoor pool entry gates self-closing and self-
Pool in good repair latching
b-2 Supervisory Personnel Pool access restricted when pool is closed
Knowledgeable pool supervisor onsite b-14 Lifeguards
List of personnel provided to Health Dept. ✓ Warning signs if no lifeguard on duty (letters
b-4 Pool Water Clarity >4" high)
✓ 6" secchi disk at pool bottom visible Warning signs visible from all entry points in
b-5 Pool Water Disinfection pool area
Automatic Feeder Used b45 First Aid Kit
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
b-16 Emergency Telephone
DPD Test Kit onsite (for disinfectant and pH)
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
P g
o enin , 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 I/ posted at entrance
Maintained in good repair, clean/sanitary Telephone numbers (print>.25") of police,fire,
Skimmers,gutters, strainer baskets clean and in hospital and EMS
good repair b-19 Registration
Drain grates compliant / Name of owner or owner's agent, address and
b-10 Deck Equipment ✓ 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
2
-2 Lifeguard stands Comments:
Lifeguard stand raised at least 4ft Type: GN
Filter T e:
Lifeguard stand located pool side adjacent to
deep end Filter Size:
c-4 Sign
No diving is permitted off the deck into Flow Gauge (gpm): I�.t l�
shallow areas of the pool"
Additional Requirements for Public Spas: TO rate (vol./flowrate x 60):
e-1 Pool Water Disinfection Filtration rate (gpm/sf):
Free available chlorine residual >1.0 mg/liter
when spa in use Free Chlorine Total 2
e-2 Pool Water Temperature �`I
Water temperature shall not exceed 104 pH:
egrees F
e-3 D th Markers
Min um 2 markers located on rim or
adjace t to pool
e-4 Precauti n Signs
"Elderly pe sons and those suffering from
Diabetes, High or Low Blood
Heart Diseas"\
Pressure, shall of enter the spa"
"Unsupervised u\dehe
n is prohibited"
"Do not use whilinfluence of
alcohol/drugs"
"Do not use alonI
"Observe a reasoimit (preferably
less than 15 mins es may result
in nausea, dizzinng"
e-5 Oils, Body Lotions, and Soaps
Oils, body lotions&soaps must be removed
prior to spa use
Pool Supervisor: C MkC_{Z'CC�IErt-._l_1�1 Date: .r'zz I
(Print Name)
1 `c�
(Signature)
LA
Health Inspector: Title: (Crimeo �TIT\,
;t,,)ature)
DATE OF COMPLIANCE: �Z�1 Re-inspection Required: 0 YES I NO
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S Windsor—April 2011