Swimming Pool/Spa Facility Information Sheet
Bureau of Water
PLEASE FILL OUT ALL THE INFORMATION REQUESTED BELOW AND RETURN TO SCDHEC POOL
INSPECTOR OR MAIL TO LOCAL SCDHEC OFFICE AT THE FOLLOWING ADDRESS:
_________________________________________________________________________________________
Date: ____________ Name of Facility:_______________________________
Permits #(S): ______________
______________
______________
Number of Indoor Pools/Spas: ___________
Number of Outdoor Pools/Spas: _______
Physical Address of Facility: ____________________________________________________________________
City:_______________________ State:____________
Zip: _____________
Phone #:_________________
Contact Information
(please print clearly)
Facility Owner's Name: ________________________________________________________________________
Address:____________________________________________________________________________________
City:________________________ State:____________
Zip:______________
Phone #:_________________
Owner's E-mail Address: _______________________________________________________________________
Management Company(if applicable): ____________________________________________________________
Address: ____________________________________________________________________________________
City:________________________ State:____________ Zip:______________ Phone #:_________________
Management E-mail Address: ___________________________________________________________________
Pool Operator of Record: _____________________________________________ Cert #:___________________
Address:____________________________________________________________________________________
City:________________________ State:____________ Zip:______________ Phone #:_________________
Pool Operator E-mail Address: __________________________________________________________________
Best Mailing Address for Invoice: ________________________________________________________________
City:________________________ State:____________ Zip:______________
Inspection Information
(please print clearly)
Designated Person to sign Inspection Forms on Site: _________________________________________________
Location where inspection form is to be left if no one is on site to sign: _________________________________
__________________________________________________________________________________________
Pool Log is Kept (Accessible Location During Inspection): _____________________________________________
Pool Equipment Room Access Code (if applicable): __________________________________________________
Form Filled Out By (print name): _____________________________ Title:_____________________________
Signature: _______________________________________________
DHEC 3441 (1/2016)
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