SP/Spa Inspection Form

Health District:

Public Swimming Pool Inspection Report Name of Facility:

Public Health Datyon-Montgomery County

Type visit

Type pool

Setting

[ X ] Standard

[

] Pool

[

] Wading pool

[

] Zero Entry

[ X ] Spray ground

Special feature (SF)

[

] Re-inspection

[

] SPA

[

] School

[

] Govt

[

] MHP

221 N MAIN STREET

[

] Complaint

[ X ] SUP

[

] Indoor

[ X ] Outdoor

[

] Camp

City:

[

] Epi Investigation

[

] Apartment/Condo

[

] Hotel/Motel

CENTERVILLE OH 45459

[

] Consulation

[

] Other

ACTIVITY CENTER SPRAYGROUND Address:

Insp Date (mm/dd/yy) 05/05/2016 Surface Area (sf)

1680 [

[

]

Flow measure reading (gpm)

]

Insp Time

Travel Time

30

Required turnover rate (min) [ie 30]

ID no.

5

] Kiddie Slide ] Playground slide ] Rec Slide ] Water Slide ] Fountain

[

] Other

License no.

10853

2016168

Required flow min:(gpm) [Volume/TRate]

Volume (gallons)

1

[ [ [ [ [

Check if in violation of the Ohio Administrative Code 3701-31-04 (A-E); NA= Not Applicable

[X]

Max allow. filter flow: (gpm) [filter label]

106

[

]

Max allow. flow: SF pump capacity (gpm)

[

]

Max allow. flow: Jet pump capacity (gpm)

Critical violations (3701-31-04(B)(1)(a-l)

[

]

(a) Outlet covers installed/secured/ in compliance

[

]

(d) Circulation/Disinfection system operating properly

[

]

(g) Water clarity; (can see pool bottom)

[

]

(j) Pool treated after RWI

[

]

(b) SVRS devices functioning

[

]

(e) Automatic chemical controller functioning properly

[

]

(h) Natural or artificial light sufficient

[

]

(k) Proper use/storage of chemicals

[

]

(c) Disinfection residual as required

[

]

(f) Lifeguards on duty

[

]

(j) Fecal accident treated properly

[

]

(l) No Electrical hazards present

Water Quality 3701-31-04 C, D (check all that apply)

[

] Calcium Hypochlorite

[ X ] Sodium Hypochlorite

[

] Bromine

[

]

(D)(6)Total Chlorine-Cl2 (ppm)

5.0

[ X ] (C)(2) pH (7.2 - 7.8)

[

] Di-Chloro

[

[

] Salt

[

]

(D)(6)Free Chlorine-Cl2 (ppm) [>= 1; 2]

5.0

[

] (C)(3)Alkalinity (ppm) [min 60]

80

[

]

(D)(6)Combined - Cl2/ (ppm) [