Free Swimming Pool Inspection Report, DPH 7205 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7205 (Rev. 05/05)

STATE OF WISCONSIN Bureau of Environmental and Occupational Health HFS 172, Wis. Admin. Code

SWIMMING POOL INSPECTION REPORT
NAME OF ESTABLISHMENT STREET ADDRESS CITY, VILLAGE OR TOWNSHIP COUNTY NAME OF LICENSEE STREET ADDRESS CITY, VILLAGE NO. OF POOLS

NAME OF PREVIOUS LICENSED ESTABLISHMENT

NAME OF PREVIOUS LICENSED OPERATOR

ESTAB. PHONE NO.

I.D. NO.

SURVEY DATE

INSPECTION STATUS Pre-Inspection................................. 1 Pre-Inspection Follow-Up................ 2 1st Inspection ................................. 3 Reg. Inspection............................... 4 Follow-Up........................................ 5 Complaint ....................................... 6 Other............................................... 7

LICENSE STATUS Release........................................... 1 Conditional...................................... 2 Withhold.......................................... 3 Suspend.......................................... 4 Operational ..................................... 5 Other............................................... 6

RELEASE DATE INSPECTION TIME FILE NOTE

Type of Pool Activity ............. 1 Cold Soak (below 72oF.)............... 2 Combination .... 3 Leisure River ... 4 Plunge ............. 5 Splash Pads .... 6 Swimming ........ 7

Ind.

Out. Therapy................8 Vanishing Edge ....9 Vortex.................10 Wading...............11 Water Attraction .12 Wave..................13 Whirlpool ............14 0 Depth Entry .....15

Year-Round Summer Winter Permit Conspicuously Displayed OPERATOR -- The violations in operating procedure or physical arrangement indicated below must be corrected by the next routine inspection or such period of time as may be specified.

DESIGN & CONSTRUCTION
01 02 03 04 05 06 07 08 09 10 11 12 13 Plans submitted, approved Pool designed and constructed 24 25

CHEMICAL & FILTER-AID FEEDING
Approved design, data plate, interwired with recirculation pump Disinfectant feeders ­ proper for chemical used, maintained, installed, operated, sized. Chemical decanted. *Gas chlorine. *CI gas safety items under #08, 11 Filter-aid feeders and chemical feeders, installed, maintained, operated Automatic monitoring and feed controls maintained, operated

SAFETY & SUPERVISION
Maintenance staff, qualified, trained Supervisor - present, qualified Staffing - no. of lifeguards Lifeguards or instructors qualified, certified Staffing - whirlpools have attendant or television camera monitored Waterslide attendant Lifeguards identifiable, no distracting duties, at duties station Safety - general, no hazardous conditions Adequate lighting, accessibility, shutoffs Rescue equipment, first aid equipment, telephone present, located, good condition, phone numbers posted; gas CI safety equipment Safety rope as required Waterslide plunge area separated Pool rules - posted, legible, located Maximum pool attendance posted, pool closed sign Chemicals - proper labeling and storage, no mixing of chemicals, smoking prohibited Security - pool enclosure, controlled access, self-closing gates and latches, access through bathhouse Pool rules enforced - communicable disease, showers, food, glass, animals prohibited. Maximum patron loading. 26 27

POOL CHEMISTRY & QUALITY
28 29 30 31 32 33 34 35 36 Approved chemicals ­ registered, measurable, compatible, nontoxic, safe Disinfectant provided, continuous, proper concentration Superoxidation - done as needed pH, alkalinity within limits or balanced Cyanuric acid - within limits Water quality - clarity, algae control Microbiology _____ Safe _____ Unsafe (Follow-up - ASAP) Temperature - within limits Accurate thermometers, approved test kits unavailable, maintained, used Frequency of testing - 2x/day-pools, 4x-/day-whirlpools; alkalinity, cyanuric acid done at least weekly Reports complete and submitted. Copies kept 2 years, available on-site

EQUIPMENT, MAINTENANCE, CLEANING
37 38 39 40 41 42 43 44 Pool equipment ­ designed, constructed Pool equipment ­ cleaned, maintained Pool and deck ­ maintained, cleaned, good repair; depth markings, boundary line General maintenance, walls, ceilings, floors, hosing; spectator area separated, maintained Toilet, shower, dressing rooms, drinking fountain provided as needed, clean, maintained, hand drying, toilet tissue Suits, caps, or towels provided to patrons - clean, thoroughly laundered, storage Water heaters, heating, ventilation and electrical provided as necessary, good repair, operated Solid waste, garbage storage and disposal

RECIRCULATION SYSTEM
14 15 16 Potable water supply; wastewater - proper disposal Separate recirculation systems for each pool - New Recirculation system continuously operated Skimmers, gutters, drains, water inlets - number, clean, good repair, installed, operated Agitation system-designed, maintained Water level maintained Proportional flow - gutter or skimmers versus drain Circulation rate-turnover Pool volume _____ gals ) flowmeter _____ gpm ) 60 = Turnover time _____ hrs. Pump installed, maintained; strainer baskets or screens clean, spares on hand Gauges maintained, operated, accurate, installed, approved; pressure or vacuum gauge _____ psi inf. _____ psi eff/comb. Surge tank operated, maintained Plumbing - air-gaps, cross-connections, maintained, installed; piping coded or labeled Filter backwashed or cleaned, maintained, operated, installed Replacement cartridges sand _____D.E. Cart. _____

17 18

19 20

21 22 23

Disinfectant used Filter aid; if any Free chlorine residual Combined chlorine Cyanuric Acid Bromine o Water temp._____ F. pH _____

Air temp. Alkalinity

ppm ppm ppm o F. ppm

SIGNATURE - Licensee or Employee

SIGNATURE - Sanitarian

DISTRIBUTION MARGIN COPY OPERATOR - White copy REGIONAL OFFICE - White copy CENTRAL OFFICE - White copy