State Form 12279 - Swimming Pool Record Of Operation - Indiana Department Of Health

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SWIMMING POOL RECORD OF OPERATION
State Form 12279 (R5 / 4-11)
INDIANA STATE DEPARTMENT OF HEALTH
Pursuant to 410 IAC 6-2.1 and 38, this form must be logged daily and retained for one (1) year.
Name of facility
Week ending date (month, day, year)
Type of pool (indoor, outdoor, wading, wave, spa, waterslide, other pool)
DAILY
WEEKLY
Name of
Person
Breakpoint chlorination /
Day
Disinfectant Residual
pH
Water
Combined Chlorine
Total
Cyanuric
Bacteriologic
Logging
Superoxidation
Cl
, Br
(ppm)
7.2 – 7.8
Temperature
(TC-FC=CC)
Alkalinity
Acid
Test
2
2
Entry
CC ≥.5 ppm
Opening
Second
Third
Opening
Second
Spa ≤104°F
First
Second
80-120 ppm
<60 ppm
Sample
Result
Amount Added
Cl
/ non-Cl
2
2
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Name of powder / solution use for disinfection
Remarks / Comments
Chemical Usage
Fecal or vomit accident,
Operating Period of
Bottom /
Fresh Water
maintenance and malfunction of
Number of
Flow Rate
Filter
Record all chemicals used in pounds / gallons.
Water Recirculation
Day
Walls
Added
equipment, shutdown of filters or
Bathers
(gpm)
Back Wash
(What time of day did
Cleaned?
(gallons)
disinfecting equipment, power
recirculation operate – hours?)
Acid
Soda Ash
Algacide
Other
failures, sickness, injuries or any
other unusual conditions
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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