HomeMy WebLinkAboutApplication 20 Summerhill Drive rKuvs
Town of South Windsor — Health Department
or - p
1540 Sullivan Avenue, South Windsor, CT 06074
Phone: 860-644-2511 ext. 250 Fax: 860-644-7280
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PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME: PARKU►E0 So O T-f-I CotNb a q-)5 o c r q ,o PJ
ADDRESS: `- aO 5i:t�MERHI� 1�R�vF
PHONE: _ _ EMAIL:
OWNER/ASSOCIATION
REPRESENTATIVE: PARK,0(E-a SoOI►-t CoNOo c to p.) F_5i FoRL� REAL E5TA1-F ►• 4Wt
ADDRESS: 34(i 4APT-FORD 'rL)IzN P tl,C 11 0EP,0Ot-3 Cr 0601.Y
PHONE: `t,(.O - 5 ZS -Z`p t S EMAIL:
MANAGER (if different from owner):
C�R^c�� Ro g r RTS
ADDRESS:
PHONE NUMBER: S 4c) _6-2 S -2 SS _ X 4
� � EMAIL:_
POOL 5AQ DL (goo L,
OPERATOR:
ADDRESS_ cl 1 Prze5 rI aT P142 is C I fZ om IF FA 5 r f4Ail rFwLa Cr vb
PHONE NUMBER -� 0--7 a-7' 009i EMAIL
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool Wading Pool Whirlpool/Spa
Dates Pool is Open: From `m2:n 01 11 to
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:
Signature tApp Title
Date
RECEIVED
'Please return completed registration form to the South Windsor Health Department. Pool Inspection requests must$A crag IWA1weeks
prior to anticipated pool opening date.
SOUTH WINDSOR
HEALTH DEPT.