HomeMy WebLinkAboutQuality Suites App 500001 04 21 16.TIF 201eS00001
N.C. Department of Environmental and Natural Resources `
Division of Environmental Health
APPLICATION FOR SWIMMING,POOL OPERATION PERMIT
POOL INFORMATION: Y� i
Name of public swimming pool: L'� u�"l-l'Y C.t 'rCI
//�/; /31 � 2 .-6'
Street address of pool location: ",
City: County: r! e Ve •0,47-41149,01- - .. .
.
Type of public swimming pool (check one) Swinmiing'pool
❑ Wading pool
D Spa .
❑ Other(describe)
Date constructed or remodeled: (check one) ❑ Before May I, 1993 -
May 1, 1993 or later /
Dates of operation: opening date _C-1/111 closing date �/ 342A
Hours of operation: opening time 62 k A o closing time /0-
OWNER INFORMATION: f
•
'Name of owner: SP-1 1' -j �-71 OF GL�(f 4uCL. .
Mailing address:
Contact person: fhc�t- P/01 et_. Telephone,.. 3 t� -327' - i
OPERATOR(On-Site Man tiger)INF�O{R_MATION: /
Name of pool operator: �q�f-i'- 7'1/`"6 I, (. C?t2-ti: ✓<7- -id&I
Address: ✓ / s h19 /9 J6 .18•. ,/-k:ce?—/ : ,Jli
Telephone number: ?°V'. _1yo- Sg/9 /
Pool operator trained by: (check one) ❑ National Sv tanning Pool Foundation . _
(Certificate Number: 0.1-0 8/2- 4 U )
❑ Other(please specf y)fn/fttielt-44; -� +�/4:r€:ci'
APPLICATION SU A1I'('Tia BY: 0:-.39 ,i At_ss:G(/ lse,.- •� .,
Owner or operator: ( ` ^ % (� 7)47--(-2_
!Ignature Typed?late ripe
Date � � ;�
ff t
Purpose Genera)Statute 130A-232 requires the Commission Health Services to adopt rules governing public swlmn ing pool.The mks in I5A '
\CAC I IA,2500 require the owner or operator to apply annually for an operation'permat lot each public swimming pool.This form is to allow.
owners or operators of public swimming pools to apply for pennies Preparation The information requested on this form is to be completed by diems ' •
pool owner or a designated representative of the owner.The completed appltcadon is submitted to the loci"health departmect'.for the county:in. •whsh the public swimming pool is located.A separate application must be completed for each public swimming pool Copies.Original to be '
maintained at the local health department..Disposition: Please refer to Reeords Retention red Disposition Schedule for County/District Health
Danarsmeols which are published by North Carolina Division of Historical.Resources Reorder.Additional Fonts may be ordered from Division n
t of bna runmental'Healt6;Department of Etwirionnient arid Natural Resources,1630 Mail Service Cen era Raleigh NC 27699 1632 (Count,52-7
DENR 3961(Revised a/63). - - - ?
.. - Gunronmental He`alch Services Section(Renew:"4106) . , '
Ati L 1.5'PR�� T-eL 2 0 0 '`), .
gCATAWBA COUNTY
i �OG 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
� PHONE: 828.465.8399
U si5,1v.4w,r Thursday, April 21, 2016
1842 sM www.catawbacountync.gov
PAYOR: Shiv Sai Hotels of QS Inc
Shiv Sai Hotels of QS Inc
PAYMENTS
TRANSACTION NUMBER: TRC-659017-21-04-2016
PAYMENT DATE : 04/21/2016
PAYMENT TYPE: Check 3350
Received in Hickory Location
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-327461 Pool Inspection Fee - Seasonal S 150.00
TOTAL PAYMENTS : $150.00
FLI-0000062
CASE TYPE: Food&Lodging Institutions WORK CLASS: 50- Seasonal Swimming Pool
SITE ADDRESS: 1125 13TH AV DR SE, HICKORY NC
Manager HOSPITALITY GROUP OF HICKORY, DBA COMFORT SUITES 1125 13TH AV DR SE, HICK(
OTHER-IMPORTED COMFORT SUITES HOTEL, 1125 13TH AV DR SE, HICKORY NC 28602
F:NONE NONE
Paid By SI-IIV SAI HOTELS OF QS INC, 1125 13TH AV DR SE, HICKORY NC 28602
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 04/21/2016 08:45 Page 1 of 1