B o a r d o f H e a l t h

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1 B o a r d o f H e a l t h March 1, Public Recreational Bathing License Application Dear Pool Owner: Enclosed you will find an application for the 2016 Public Recreational Bathing License and a preoperational checklist. The completed forms and appropriate fee should be returned prior to scheduling a pre-operational inspection. Pools which are open year-round should utilize the checklist as a self inspection form. The licensing fee is $ Seasonal pools require inspection prior to operation. Appointments can be scheduled by contacting the Health Department at The pre-operational inspections will examine all aspects of compliance with the New Jersey Public Recreational Bathing Rule, N.J.A.C. 8:26. In preparation, please ensure the following requirements will be in place at the time of the inspection. Bacteriological Lab Results Water Clarity and Chemical Parameters Main Drain Certification and Documentation Annual Electrical Certificate of Compliance Valid Electrical Bonding and Grounding Aquatic Supervision Plan Certifications for a Trained Pool Operator and Lifeguard Owners and operators are also encouraged to review their facility s compliance with the American Disabilities Act (ADA) pool entry requirements. This law is enforced by the US Department of Justice. Guidance materials are available at I encourage you to contact our office as early as possible to schedule pre-operational inspections. If you have any questions in regards to the above, please do not hesitate to contact the Health Department at Sincerely, Jill M. Swanson Health Officer

2 TOWNSHIP OF ROBBINSVILLE DEPARTMENT OF HEALTH 1 WASHINGTON BLVD., SUITE 5 ROBBINSVILLE, NJ Phone ext. 120 Fax Name of Facility PUBLIC RECREATIONAL BATHING PLACE LICENSE APPLICATION Onsite Phone Number Location Name of Owner(s), Corporation, or Registered Agent Street Address State Zip Phone Pool Management Company Name Address Phone Name of trained operator (CPO) Dates of Pool Operation Emergency Phone Contact TO (If N/A please check box ) Hours of Pool Operation Bonding and Grounding Certification Date TO Electrical Inspection Date The undersigned owner, representative, or manager agrees to operate this facility in compliance with the standards set forth in the New Jersey Sanitary Code, Chapter IX, Public Recreational Bathing, N.J.A.C. 8:26. The undersigned also certifies that this facility has not been altered from its approved design without the required review and approval of the Health Department. Changes to the pool structure, the recirculation equipment or flow of water, and modifications of the disinfection system are alterations which require plan review and approval from the local health authority. Name (Print) Signature of Owner Date FEE SCHEDULES: $ FOR OFFICE USE ONLY: Please enclose the license fee made payable to the Township of Robbinsville: LICENSE # ISSUED: PAID $ CHECK #: CASH: Rev. 4/2013

3 XA Public Health Sanitation and W MRSEV Ir Safety t Progr;ilwn Ntat?N 3 Public Health Sewwas Free Chlorine R* sidual Guidance Document With regard to the current national standard established by the American National Standards Institute ( ANSI) 1, " Public Swimming Pools", the Public Health Sanitation and Safety Program in the New Jersey Department of Hr;)alth and Senior Services ( NJDHSS), is providing a guidance document regarding the levels of free chlorine and bromine in New Jersey public pools. With Recreational Water Illnesses ( RWI) on the rise every summer, the NJDHSS acknowledges that increasing the free chlorine or bromine levels to national guideline levels can only benefit the public. In ANSI 1, the levels should meet the following standards: free chlorine levels should be between 1. 0 and parts per million ( ppm) with bromine levels between 2. 0 and ppm. ANSI' s ideal range is 2. 0 to 4. 0 ppm for swimming pools. In whirlpools, spas and hot tubs, the free chlorine and bromine levels continue to be between 2. 0 to ppm with an ideal range of 3. 0 to 5. 0 ppm as in N. J. A.C. 8: 26 ( Public Recreational Bathing rule). With that said, if a facility wishes to exceed the cump',, mt levels found at N. J. A.C. 8:26-7.8, ' a maximum of 4. 0 ppm for free chlorine in swimming r: ools', the NJDHSS will require that all public pool water quality to be within the acceptable standards for all other parameters: 1. ph ( ), 2. combined chlorine (<. 2), 3. total alkalinity ( 60 to 180), 4. stabilizer ( cyanuric acid - 5. pool water clarity (the deepest portion of the 1r:;) ool floor shall be clearly visible from the swimming pool's edge). 10 to 100 ppm and only in outdoor pools) and; In addition, the maximum disinfectant level shall also,;,,be determined by the capabilities of the test kits utilized. The test kit must give an accur@,ate reading of the actual level of disinfectant available. Therefore, for example, if the irnaximum detectable level of the test kit is 8. 0 ppm, then the maximum level of free chlorine or bromine is 7. 0 ppm. Also, please be advised that this is a guidance policy. It is the local health authorities' LHA) jurisdiction to permit this exceedance of the clurrent maximum levels of disinfectant found at N. J. A.C. 8: All the other operational parameters must also be in compliance for the approval by a LHA. If you have any questions, please feel free to contar:-t the Public Health Sanitation and Safety Program at ( 609) or via at loel. state. nj. us.

4 New Jersey Department of Health Consumer, Environmental and Occupational Health Service CHECKLIST FOR PUBLIC RECREATIONAL BATHING FACILITIES Municipality Local Health Authority Date Name of Public Recreational Bathing Facility Dates of Operation Type of PRB Facility PRB Facility Location Phone Number Special Exempt Yes No Both Owners Name and Address Phone Number Certified Laboratory Phone Number Date of Last Sample Trained Pool Operator Address Phone Number TPO Certification No. and Exp. Date Lifeguard Certifications Current Pro CPR Certifications Current Aquatics Facility Plan Water Sample(s) Results Sanitary Surveys (8: ) Emergency Phone Numbers Pool/Natural Waters Rules Sign No Diving Signs Caution Chemical Sign No Smoking Sign (Chem. Room) Depth Markings Codes: X-Compliant P-Pending N/A-Not Applicable PAPERWORK Log Book GENERAL LAYOUT Bonding and Grounding (5-year cert.) Bonding and Grounding (Town) CB-20 completed and submitted MSDS sheets for all chemicals Physical Hazards inspection No Lifeguard on Duty Sign Adult Supervision Sign Special Exempt Signs Spa Clock Spa Rules Diving Rules Entrance(s) Secure Cliff Jumps < 15 Floats and Fixed Platforms Permitted with LHA Approval Diving stands, boards, ladders, stairs, all equipment maintained Water slides conform to CPSC and approved by LHA and/or NJDCA Rope drops, cliff jumping, and aquatic play equipment meet N.J.A.C. 5:14A-12 Surface area (Pool sq ) Volume (Pool) Equipment for continuous disinfect all types pool water and meet 8: Pool chemicals stored, handled and used per manufacturer's instructions Anti-entrapment drain covers installed, all documentation on site Pool Floor (Clean and Visible) Turnover Rate(s) (Pool) Pump Maximum Flow Rate(Pool) CEOH-1 NOV 12-1-

5 Name of Public Recreational Bathing Facility CHECKLIST FOR PUBLIC RECREATIONAL BATHING FACILITIES (Continued) Facility Phone Guard (Uniform/Whistle) DPD Test Kit First Aid Kit Rescue Tube(s)/LG Backboard Straps Head Immobilizer Shepherd Hooks Reaching Poles/Assist Safety Rope and Floats Ring Buoys Thermometer Goggles and Gloves Emergency numbers posted Codes: X-Compliant P-Pending N/A-Not Applicable EQUIPMENT Vacuum Equipment Skimmer Net # of Returns Sight glass Entrapment Issues Spa Requirements Wading Pool Requirements Circulation System Flow Meters Continual Disinfection Device Secure Fencing Self Close/Self Latching Gates Diving Boards Water Clarity Lifeguard platforms or stands Paddle Rescue Device Emergency care room (500+) Bathrooms (Cleaned and Stocked) Separate BR facilities (each sex) Sanitary facilities maintained and constructed of impervious materials Floors have slip-resistant surface Suitable receptacles provided for paper towels and waste materials Soap dispenser provided, hot and cold water GENERAL SANITATION AND MAINTENANCE Only unbreakable mirrors provided Sanitary sewage and filter backwash waters handled properly Solid waste stored in watertight containers with tight-fitting lids Potable water supply source and of safe and sanitary quality All buildings rodent and insect proofed Premises maintained to prevent the breeding and harborage of vermin CHEMICALS / DISINFECTANTS (POOLS) Free Chlorine (10 ppm max) ph ( ) Total Chlorine (ppm) Combined Chlorine (<.2) Other Disinfectant Total Alkalinity ( ppm) Calcium Hardness (ppm) Cyanuric Acid (10-100ppm) Outdoor CEOH-1 NOV 12-2-

6 Name of Public Recreational Bathing Facility CHECKLIST FOR PUBLIC RECREATIONAL BATHING FACILITIES (Continued) Codes: X-Compliant P-Pending N/A-Not Applicable SUPERVISION Operations supervised by an adult Aquatics Facility plan executed Standard first aid and Pro CPR All lifeguards identifiable Pools have TPO,TPO onsite weekly Lifeguards equipped with a whistle Adequate number of Lifeguards Emergency Drills documented BATHING WATER QUALITY Pool water approved water source Pool chemistry monitored (2 hrs) Water samples collected weekly Deaths/serious injuries reported 1 st sample failed warning signs 2 nd sample failure closure signs COMMENTS I verify that the statements made in this form are true and accurate and this Public Recreational Bathing facility meets the requirements of N.J.A.C. 8:26 et seq., I understand that all the information provided, if falsified, can be used against me in court, by the authorities. Signature of Owner/TPO Title or Position CEOH-1 NOV 12-3-

7 Notice to Pool Owners Renovations, Repair, Replacements Please be advised that the owners of public pools are responsible for obtaining any permits and/or approvals required for renovation, repairs, or replacement work performed at the facility. Construction Permits Pursuant to the Uniform Construction Code, any work that is not listed as ordinary maintenance under the UCC, requires a permit from the Construction Department. If you have questions about a specific project and applicable permits, contact the Construction Department at Health Authority Approval Approvals are required whenever a facility proposes to alter a bathing facility. Alter is defined as any modification, or relocation of any structure or equipment, or diversion and change of water flow patterns in an existing public recreational bathing place such that the design, configuration and/or operating characteristics are different from the original design, configuration and/or operating characteristics. The term does not include normal maintenance, repair, or replacement of previously approved equipment. [NJAC 8:36-1.3] Applications should be submitted to the Health Department. Please call for additional information;