Public Aquatic Facilities Assessment

• Trading Name

• Proprietor

• Conducted on

  Date
• Location
  Address

• Person interviewed

• Phone number

• Email address

Log Book Maintenance

• Type of Test Kit?

  Colorimetric

  Photometric

• Have records of the following parameters been maintained at the frequency specified?

  Yes

  No

  N/A

• Keeping Records
  Log books to be kept for at least 12 months after the last entry and available on demand to an authorised officer.
  

• Free Chlorine recorded daily

  Yes

  No

  N/A

• Total Chlorine recorded daily

  Yes

  No

  N/A

• Total Bromine recorded daily

  Yes

  No

  N/A

• Combined Chlorine recorded daily

  Yes

  No

  N/A

• pH recorded daily

  Yes

  No

  N/A

• Alkalinity recorded daily

  Yes

  No

  N/A

• Cyanuric acid recorded weekly

  Yes

  No

  N/A

• Have records been kept for the previous 6 months?

  Yes

  No

  N/A

• Incident response plan

  Yes

  No

  N/A

• Comments or actions required?

CHLORINE POOLS & SPAS

• Chlorine Pool

Pool

• Description

• Pool photo

  Media

• Pool type

  Select Diving Olympic Toddler Spa leisure

  • Diving
  • Olympic
  • Toddler
  • Spa
  • leisure

• Surface

  Concrete

  Fibre glass

  Liner

• Disinfectant System

  Select Metered gas Automatic salt chlorination Salt Chlorinator Metered liquid Chlorine

  • Metered gas
  • Automatic salt chlorination
  • Salt Chlorinator
  • Metered liquid Chlorine

• Auxiliary system

  Select Cyanuric UV light Ozone ionic other none

  • Cyanuric
  • UV light
  • Ozone
  • ionic
  • other
  • none

• Bathing load at the time inspection

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Is the pool clean and free of debris

  Yes

  No

  N/A

• Free Chlorine (mg/L)

• Total Chlorine (mg/L)

• Combined Chlorine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Cyanurate (mg/L)

• Comments or actions required?

• Chlorine Spa

Spa

• Description

• Spa photo

  Media

• Spa type

  Select Diving Olympic Toddler Spa leisure

  • Diving
  • Olympic
  • Toddler
  • Spa
  • leisure

• Disinfectant System

  Select Metered gas Automatic salt chlorination Salt Chlorinator Metered liquid Chlorine

  • Metered gas
  • Automatic salt chlorination
  • Salt Chlorinator
  • Metered liquid Chlorine

• Bathing load

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Is the spa clean and free of debris

  Yes

  No

  N/A

• Free Chlorine (mg/L)

• Total Chlorine (mg/L)

• Combined Chlorine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Cyanurate (mg/L)

• Comments or actions required?

BROMINE POOLS & SPAS

• Bromine Pool

Pool

• Description

• Pool photo

  Media

• Pool type

  Select Diving Olympic Toddler Spa leisure

  • Diving
  • Olympic
  • Toddler
  • Spa
  • leisure

• Disinfectant System

  Select Metered gas Automatic salt chlorination Salt Chlorinator Metered liquid Chlorine

  • Metered gas
  • Automatic salt chlorination
  • Salt Chlorinator
  • Metered liquid Chlorine

• Bathing load

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Is the pool clean and free of debris

  Yes

  No

  N/A

• Total Bromine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Comments

• Bromine Spa

Spa

• Description

• Pool photo

  Media

• Spa type

  Select Diving Olympic Toddler Spa leisure

  • Diving
  • Olympic
  • Toddler
  • Spa
  • leisure

• Disinfectant System

  Select Metered gas Automatic salt chlorination Salt Chlorinator Metered liquid Chlorine

  • Metered gas
  • Automatic salt chlorination
  • Salt Chlorinator
  • Metered liquid Chlorine

• Bathing load

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Is the spa clean and free of debris

  Yes

  No

  N/A

• Total Bromine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Comments or actions required?

Pool Facilities

• Toilets/Change Rooms/Showers - clean, state of good repair, able to be effectively cleaned?

  Yes

  No

  N/A

• Pool water clean, walls clean and drains clear?

  Yes

  No

  N/A

• Chemical storage - chemicals labelled, location suitable

  Yes

  No

  N/A

• Comments or actions required?

Signatures

• Proprietor's Signature

  Sign

• Environmental Health Officer

  Sign

Contact

• Environmental Health Officer
  Wentworth Shire Council
  PO Box 81
  Wentworth NSW 2648
  
  P: 03 50275023 F: 03 50275000 E: council@wentworth.nsw.gov.au

Want More Information?

• Further information can be viewed at www.health.nsw.gov.au and search for Swimming pools