20 CAR pt. 136, Appendix G
ENVIRONMENTAL HEALTH PROTECTION ENVIRONMENTAL HEALTH SERVICES
NAME OF POOL: ____________________ MANAGER: ____________________ ADDRESS: ____________________
| CHEMICAL READINGS | CHEMICALS ADDED | WATER TEMP. | MAKE-UP WATER | FILTERS BKWASHED | BATHER LOAD | ACCIDENT * | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DATE | FREE CHLOR | PH | TOTAL CHLOR | ALKAL | CYAN. ACID | HARD- NESS | CHLOR | SODA ASH | ACID | OTHER | |||||
REMARKS: ____________________
Keep original in your files; on request, submit to your county sanitarian.
* COMPLETE ACCIDENT REPORT FORM
Signature