STATE OF FLORIDA
DEPARTMENT OF HEALTH
MONTHLY SWIMMING POOL REPORT
STATE PERMIT #     		DATE     	

NAME OF POOL       	  ADDRESS       	
Days 
 of
month	Chlorine 
residual	
pH	
Filter Gauge Reading	
POOL VOLUME IN GALLONS     ___________________
		
	9 AM	1 PM	4 PM	9 AM	1 PM	4 PM	Vacuum 

in/Hg
	Pressure:
Influent
PSI	Pressure:
Effluent
PSI	Flow
GPM
	Pool
Vacuumed	No. Patrons	Remarks
Enter items such as:  Total alkalinity, hardness, cyanuric acid, equipment breakdown, excessive pool water loss, filter backwash, water clarity	
1	    	    	    	    	    	    	    	    	    	    	    	    	     	
2	    	    	    	    	    	    	    	    	    	    	    	    	     	
3	    	    	    	    	    	    	    	    	    	    	    	    	     	
4	    	    	    	    	    	    	    	    	    	    	    	    	     	
5	    	    	    	    	    	    	    	    	    	    	    	    	     	
6	    	    	    	    	    	    	    	    	    	    	    	    	     	
7	    	    	    	    	    	    	    	    	    	    	    	    	     	
8	    	    	    	    	    	    	    	    	    	    	    	    	     	
9	    	    	    	    	    	    	    	    	    	    	    	    	     	
10	    	    	    	    	    	    	    	    	    	    	    	    	     	
11	    	    	    	    	    	    	    	    	    	    	    	    	     	
12	    	    	    	    	    	    	    	    	    	    	    	    	     	
13	    	    	    	    	    	    	    	    	    	    	    	    	     	
14	    	    	    	    	    	    	    	    	    	    	    	    	     	
15	    	    	    	    	    	    	    	    	    	    	    	    	     	
16	    	    	    	    	    	    	    	    	    	    	    	    	     	
17	    	    	    	    	    	    	    	    	    	    	    	    	     	
18	    	    	    	    	    	    	    	    	    	    	    	    	     	
19	    	    	    	    	    	    	    	    	    	    	    	    	     	
20	    	    	    	    	    	    	    	    	    	    	    	    	     	
21	    	    	    	    	    	    	    	    	    	    	    	    	     	
22	    	    	    	    	    	    	    	    	    	    	    	    	     	
23	    	    	    	    	    	    	    	    	    	    	    	    	     	
24	    	    	    	    	    	    	    	    	    	    	    	    	     	
25	    	    	    	    	    	    	    	    	    	    	    	    	     	
26	    	    	    	    	    	    	    	    	    	    	    	    	     	
27	    	    	    	    	    	    	    	    	    	    	    	    	     	
28	    	    	    	    	    	    	    	    	    	    	    	    	     	
29	    	    	    	    	    	    	    	    	    	    	    	    	     	
30	    	    	    	    	    	    	    	    	    	    	    	    	     	
31