| Inspecting Officer: |
| Time: |
| Date: |
| Name and Address of Facility: |
| Phone No.: |
| Manager: |
| Supervisor/Operator on duty at time of inspection: |
| | REMARKS |
| I | GENERAL | |
| 5 | Life guard present | |
| 5 | Operation records and testing | |
| 3 | Structure defects absent | |
| II | SAFETY | |
| 3 | At least 2 ladders/steps present at deep and shallow end of pools | |
| 5 | Permanent depth marking present at least 4 inches high | |
| 3 | Life line pole and first aid kit provided and used | |
|
| 5 | Electrical hazards absent | |
| 2 | Spectator area separate from pool | |
| 5 | Chemicals properly stored | |
| 5 | Gas mask available outside of chlorinator room | |
| | REMARKS |
| III | OPERATIONS | |
| 5 | Proper disposal of filter backwash waste water | |
| 2 | Absence of cross connection | |
| 2 | Air gap provided | |
| 2 | Adequate skimmers functioning | |
| 2 | Flow meters operable | |
| IV | WATER QUALITY | |
| 5 | Pool clarity/black disc on pool bottom | |
| 5 | Records Maintained | |
| 5 | Residual chlorine 2.0 – 3.0 ppm | |
| pH 7.5 – 8.4 | |
| 5 | Bacteriological quality, 0 FC in 100ml of water. | |
| 4 | Chemical treatment equipment operable | |
| 2 | Proper operation of recirculation system | |
| 4 | Bottom/sides/gutter and deck clean/ non-slip type | |
| V | BATH HOUSE/OTHER FACILITIES | |
| 4 | Adequate number of showers for each sex/operable clean | |
| 4 | Toilet facilities adequate separate sex/operable/clean | |
| 3 | Soap, suitable hand washing facilities (towels, soap, dispensers etc.) | |
| 5 | Suitable sign(s) exempting certain persons from bathing in pool/forbidding spitting | |
| 5 | Valid permit to operate | |