N.C. Department of Environment and Natural Resources
Division of Environmental Health
Inspection of Swimming Pool
Demerit Score:
Date of Insp/Chg
Status Code:
Health Department
Current Facility ID __ __ __ __ __ __ __ __ __ __ __
Old Facility ID __ __ __ __ __ __ __ __ __ __ __
1 Community 3 Non-Transient Non-Community Water sample taken today? YES NO
2 Transient Non-Community 4 Non-Public Water Supply 1 Inspection Name Change
2 Re-Inspection Verification of Closure
1 Community 2 On-Site Systems V Visit Status Change
stablishment: Pool Operator:
Mailing Addr.:
State: NC Zip: City: State: Zip:
WATER QUALITY: (.2535)
Points
Deducted
(Circle)
* Indicates critical item (6-point demerit)
*1. Water clear enough to clearly see bottom of pool and pool drain ……….. 6
*2. Disinfectant residual provided by:
free chlorine = ________(at least 1.0 ppm or 2.0 ppm where required);
bromine = ________ (at least 2.0 ppm); or
biguanide = ________ (30 to 50 ppm………………………………………. 6
*3. Pool water pH = ________ (7.2 to 7.8)……………………………………… 6
*4. Water temperature of heated pool __________°F; does not exceed 90°F
(swimming pool) or 104°F (spa) …………………………………………… 6
5. Daily written records of water quality and test kit kept on site ...…………… 4
POOL MAINTENANCE:
*6. Main drain covers secured and in good repair, no suction hazard. Single
drains protected by April 1, 2006 (.2537, .2539)……………………………
6
7. Pool walls and floor kept clean, free of debris and in good repair (.2537)…… 4
8. Surface skimmers (with weirs, baskets and covers) or gutters clean, in good
repair, and functioning properly, no floating debris (.2518, .2537) …………..
4
9. Depth markings and no diving markers or signs visible and properly located
(.2523, .2537)……………………………………………………………………
4
10. Safety ropes with floats and contrasting color bands provided at shallow area
breakpoints (.2515, .2523)……………………………………………………...
2
11. Diving equipment, ladders, steps and handrails properly placed, in good repair
(.2517, .2521)………………………………………………………………….
2
12. Inlets and other fittings in place and in good repair (.2537)…………………… 4
13. Contrasting band on steps and benches (.2521, .2516, .2532)…………………. 4
14. Spa timer working properly (.2537)……………………………………………. 4
PREMISES:
*15. Body hook and ring buoy with throw rope or lifeguard with rescue tube
provided and properly located (.2530, .2537) ……………………………….
6
16. Fence or barrier with self-closing, self-latching gates properly constructed and
maintained (.2528, .2537) ……………………………………………………..
4
17. Decks unobstructed, properly drained, free of trip hazards (.2522, .2537……… 4
18. Lifeguards present or warning signs posted (.2530) …………………………… 4
19. Signs prohibit glass containers or pets in pool area(.2530) ……………………. 4
20. Caution signs posted at hot water spas (.2532) ………………………………… 4
21. Pool and deck lighting provided at pools that operate at night (.2524, .2537) … 4
*22. Emergency telephone provided (.2530) ………………………………………. 6
EQUIPMENT ROOM:
23. Chlorine or bromine automatic feeders that meet NSF Standard 50 (.2535) ….. 4
24. Approved pump, filter, and flow meter operating properly (2518, .2519) …….. 4
25. Equipment and chemicals kept in a dry, well-ventilated enclosure (.2533, .2534,
.2537) …………………………………………………………………………….
2
26. Valves and pipes identified by color codes or labels (.2518) …………………… 2
27. Filter backwash discharged through an air gap (.2513) ……………………….… 2
DRESSING AND SANITARY FACILITIES:
28. Bathhouse or rest rooms accessible; shower sign posted (.2526) ………………. 2
29. Required fixtures provided, clean, and in good repair (.2526) …………………. 2
30. Approved water source, no cross connections (.2512) …………………………. 2
31. Sewage disposed of in a properly operating sewage system (.2513) ………….… 2
32. Floors smooth, slip-resistant, kept clean(.2526) ………………………………… 2
33. Hose bibbs and floor drains provided (.2526) ………………………………….. 2
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Inspection Conducted by: EHS I.D.# Comment Sheet Attached
Report received by: Yes No
Purpose: General Statute 130A-282 requires the Commission for Health Services to adopt rules governing Public Swimming Pools. 15A NCAC 18A .2511 specifies the contents of an inspection form to r
results of inspections. This form is developed to be used in making inspections of public swimming pools, spas, wading pools and water recreation attractions. Preparation:
Local environmental health specialists shall
complete the form every time they conduct an inspection. Prepare an original and two copies for: 1. Original to be left with the responsible person. 2. Copy for the local health department. 3.
Copy for the Environmental
Health Services Section, Division of Environmental Health. Disposition: This form may be destroyed in accordance with Standard 7, Inspection Records, of the Records Disposition Schedule
Division of Archives and History. Additional forms may be ordered from: Division of Environmental Health, 1630 Mail Service Center, Raleigh, NC 27699-1630.
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DENR3960 (Revised 03/05
Environmental Health Services Section (Review 03/08)