Sample Form Courtesy of Douglas County Health Department

(Sample form courtesy of Douglas County Health Department)

SAMPLE FORM: Non-Residential Swimming Pool or Spa Inspection

Date: ______

Name: ______

Address: ______

Operator/manager: ______

Maintenance by: ______

Satisfactory / Unsatisfactory
(see Remarks) / Operation Requirements
Disinfection-pH Level-Testing&Recording-Filtration-Water Clarity
q pool: free chlorine residual between 0.4 and 5.0 ppm
q spa: free chlorine or bromine residual between 2.0 and 5.0 ppm

Note: Any pool or spa found to have less than the minimum required free chlorine or bromine residual shall be ordered closed immediately by the Health Department. The pool or spa may be re-opened by the management when the minimum chlorine or bromine residual is achieved.

Disinfection system operational
Disinfectant supply: (circle one)
Solid – Liquid -- Gas Chlorine -- Other
pH level between 7.2 and 7.8
Pool water test kit available
Operating log available
Filtration system: (circle one)
Sand -- Diatomaceous Earth -- Other
Water clarity allows visualization from the deck to the deepest part of pool or spa
Satisfactory / Unsatisfactory / Safety Requirements
Backflow Prevention - Outdoor Fencing - Locking Gates - Signs
Anti-vortex Drain Covers - Spa Temperature - Rescue Equipment
Backflow prevention: (circle one)
Air Gap -- Vacuum Breaker -- RPZ valve
6’ fencing if outside enclosed building
Lockable gated, doors, or other entrances
‘NO LIFEGUARD ON DUTY’ sign conspicuously posted if applicable
Anti-vortex drain covers or grates installed to prevent body/hair entrapment
Spa water temperature does not exceed 104 degrees F
At least one 12-foot life pole or shepherd’s crook available at pool side
At least one ring buoy available at pool side, attached to rope (3/4 the pool length)

REMARKS:

Inspected by: ______Received by: ______