HomeMy WebLinkAboutAdrian L Shuford App 530057 04 04 16.TIF FLi- o= 33
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N.C.Departmentof Environmental and Natural Resources
Division of Environmental Health
APPLICATION FOR-SWIMMING POOL OPERATION PERMIT
FOOL INFORMATION:
Name ofpublicswimmingpool: Re-Arlan L 511...4.0-e,\ 3c, Thc-tti \?wcA
Street address ofpool location: _\b,,Ut Conover PA v3 e .
City: County: Censpve: Cof'c.whc,
Type of public swimming pool(check one) Swimming pool
Wading pool
Spa
Other(describe)
Date constructed orremodeled:(check one) BeforeMay1,1993
May 1,1993 or later
Dates of operation: opening date tfica j C ov.>1rk closing date
Hours of operation: opening time 5 too 4 M closing Hine GI°.E to PM
OWNER INFORMATION:
Name of owner; `1.10,6/1 o p C0.I{>W\a2i 5..t'e
•
Mailing address: A3`75 LR 3\vr;1 5ut•)It 'le'2 1.4 ...rh'ory 26tc0Z_
Contact person: r,. N''eLo f 'Telephone: (?3) tl-lig- 0 130
OPERATOR(On-Site Manager)INFORMATION:
/11
Name ofpool operator: el e)'-, N;4-kW '
Address: Zyav1 `74Von Si f-e till•'/ NC -25bLi1
Telephone number: (. t-2 0 -7 4 .)., u
Pool operator trained by:(checkone) National Swimming Pool Foundation
in (Certificate Number: (12*6&77," 1.1 )
R Other(please specify) NC CPC
APPLICATION SUBMITTED BY: 7 //-�
Owner or operator: �� / �H `� AA'eh f
gnnture Typed or printed name
Date: LI 'ltllls
PuryoseGeneraiStatute 130A- 82requires the Commission Health Som icestoadoptmlesgoverning publicswiminingpools.Therulesin 15A
NCACISA.2500 require the owner or operator to apply annually for an operation permit for each public swimming pool This form is to allow
owners or operators of pubicswimming pools to apply for penile.Preparation:The information requested on this form is to be completed by the
pool owner or a designated representative of the owner.The completed application is submitted to the local health department for the sourly In
which the public swimming pool is located.A separate application must be completed for each pubic swimming pool.Copies:Original lobe
maintained at the local health department,Disposition:Please refer to Records Retention and Disposition Schedule for Counly/Disllet Health
Departmentswhich ere published by North Carolina Dlvlslonof Historical Resources.Reorder.Additional Forms may he ordemd/ram:Division
of Environmental Health,Departmentof Environment and Natural Resources,1630 Mail Service Center,Raleigh,NC 27699-1632,(Courier 52-
01-00)
DENR 3961(Revised 4/03)
Environmental Health Services Section(Review4/06)
("Hce,A co CATAWBA COUNTY,ia I00A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
�> PHONE: 828.465.8399
U g:. h-s4 Monday, April 4, 2016
\842 sM www.catawbacountync.gov
PAYOR: YMCA OF CATAWBA VALLEY
YMCA OF CATAWBA VALLEY
PAYMENTS
TRANSACTION NUMBER: 1RC-649363-04-04-2016
PAYMENT DATE : 04/04/2016
PAYMENT TYPE: Credit Card
160998646
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-326817 Pool Inspection Fee- Year Round $200.00
TOTAL PAYMENTS : $200.00
FLI-0000185
CASE TYPE: Food& Lodging Institutions WORK CLASS: 53 -Year-Round Swimming Po
SITE ADDRESS: 1 104 CONOVER BLVD E, CONOVER NC
Manager YMCA OF CATAWBA VALLEY INC, PO BOX 280,CONOVER NC 28613
OTHER-IMPORTED ADRIAN L SHUFORD JR YMCA, PO BOX 280, CONOVER NC 28613
F:NONE NONE
Paid By YMCA OF CATAWBA VALLEY, 1375 LENOIR RHYNE BLVD, HICKORY NC 28602
B:8283249622
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 04/04/2016 12:41 Page 1 of I