Weekly Water Quality Report Form
Facility Name: _______________________________________________________________________________________________ Week Date From: _____ /_____ /20_____ to _____ /_____ /20_____
Type of Pool
Swim
Spa
Wade
Activity
Disinfectant CI (Br x 2)
Day Date
Monday
_________
Tuesday
_________
Wednesday
_________
Thursday
_________
Friday
_________
Saturday
_________
Sunday
_________
Time
of Day
Suction
Outlets
Free 1-10
Spa 2-10
Combined
<+0.5
pH
7.2-7.8
Lap
Flow
Rate
Min=___
ORP
(>700)
Therapy
Temp
Max=
104°F
_____________
Alk
>50ppm
_________
Cyanuric
Acid
<100
_________
Filter
Pressure
(psi)
Comments:*
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
*Manual Chem Feed, Backwash, Breakdowns, Injuries, Accidents, CPOs Initials
Minnesota Department of Health, Swimming Pool Engineering
P.O. Box 64975, St. Paul, Minnesota 55164-0495
651-201-4503
http://www.health.state.mn.us/divs/eh/pools/
December 2016 Rev 2.0