Public swimming pool and spa inspection form

• Proprietor

• Document No.

• Trading Name

• Conducted on

  Date

• Prepared by

  Select Josh Smith Dan Bugitti Daryl Pasfield Philip Martin

  • Josh Smith
  • Dan Bugitti
  • Daryl Pasfield
  • Philip Martin
• Location
  Address

• Time of inspection

  Date

• Person interviewed

• Log book maintained

  Yes

  No

  N/A

• Email address

CHLORINE POOLS & SPAS

• Chlorine Pool

Pool

• Description

• Pool photo

  Media

• Pool type

  Select Outdoor Indoor

  • Outdoor
  • Indoor

• Disinfectant System

  Select Metered Automatic

  • Metered
  • Automatic

• Bathing load

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Free Chlorine (mg/L)

• Total Chlorine (mg/L)

• Combined Chlorine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Cyanurate (mg/L)

• Calcium

• Is the pool clean and free of debris

  Yes

  No

  N/A

• Comments

• Chlorine Spa

Spa

• Description

• Spa photo

  Media

• Spa type

  Select Outdoor Indoor

  • Outdoor
  • Indoor

• Disinfectant System

  Select Metered Automatic

  • Metered
  • Automatic

• Bathing load

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Free Chlorine (mg/L)

• Total Chlorine (mg/L)

• Combined Chlorine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Cyanurate (mg/L)

• Is the pool clean and free of debris

  Yes

  No

  N/A

• Comments

BROMINE POOLS & SPAS

• Bromine Pool

Pool

• Description

• Pool photo

  Media

• Pool type

  Select Outdoor Indoor

  • Outdoor
  • Indoor

• Disinfectant System

  Select Metered Automatic

  • Metered
  • Automatic

• Bathing load

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Free Bromine (mg/L)

• Total Bromine (mg/L)

• Combined Bromine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Comments

• Bromine Spa

Spa

• Description

• Pool photo

  Media

• Spa type

  Select Outdoor Indoor

  • Outdoor
  • Indoor

• Disinfectant System

  Select Metered Automatic

  • Metered
  • Automatic

• Bathing load

  Select Light Medium Heavy

  • Light
  • Medium
  • Heavy

• Free Bromine (mg/L)

• Total Bromine (mg/L)

• Combined Bromine (mg/L)

• pH range

• Total Alkalinity (mg/L)

• Comments

Recommendations

• Comments

• Environmental Health Officer

  Sign