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FJ cI2) RECEIVED
N.C. Department of Environmental and Natural Resources
Division of Environmental Health APR 3 218
APPLICATION FOR SWIMMING POOL OPERATION PERMIT CATMQ 3hrCOUN;L- N
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POOL INFORMATION: r I LL ENV1Rr 1Pn
Name of public swimming pool: Fa; r 4-;e Id Inn i— S- - 5
Street address of pool location: /953 /3 A V t Ar 3E
City: County: I-) ;Gtor-i( (a1-Ccwha
Type of public swimming pool (check one) W Swimming pool
❑ Wading pool
❑ Spa
❑ Other (describe)
Date constructed or remodeled: (check one) ❑ Before May I, 1993
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❑ May 1, 1993 or later
Dates of operation: opening date / 1 Cud /9 9(p closing date
Hours of operation: opening time (D A-ti closing time I I pm
OWNER INFORMATION: II Mn
Name of owner: Piear-non -1- A
(en-kr 55oc;o4-e5
Mailing address: n/a a J5 ' I-1w y 7Q 1/45E Nt`Jor ,N( p2ito 002
Contact person: lienee PN e e Vr..( Telephone: -3, ) - eigas
OPERATOR (On-Site Manager)INFORMATION:
Name of pool operator: A0her-4- Lyntm /TS�af(en+ ' / /,
Address: /960 /3 is Ave l r .SE( /- ;ckon( ; NC 02242
Telephone number: gag - y31 - 3060J
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number: 1
Iki'. Other (please specify American 560'1 m fp, Poo' Spa
APPLICATION SUBMITTED BY:
Assoc. yes:a 03ao) R_ JD
Owner or operator: A "r da,Q�qa9 Pod < et L yN it2 7.-Cilie n°-42'
Signature Tyoed or nrinled name 2
Date: `12 S 1.t
Purpose General Statute I30A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in I 5A
NCAC 18A.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 public swimming pools to apply for permits.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 county in
which 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 Records Retention and Disposition Schedule for County/District health
Departments which are published by North Carolina Division of Historical Resources.Reorder:Additional Forms may be ordered from:Division
of Environmental Health,Department of 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(Review 4/06)
CATAWBA COUNTY
���� I00A SOUTHWEST BLVD
NEWTON.NORTH CAROLINA 28658 RECEIPT
d �� dPg PHONE:828.465.8399
p]!'D.:vpv `'� Monday,April 30,2018
1842 SM www.cutawbacountync.gov
PAYOR:
FAIRFIELD INN HICKORY LLC.
PAYMENTS
TRANSACTION NUMBER: TRC-3518673-30-04-2018
PAYMENT DATE: 04/30/2018
PAYMENT TYPE: Check 26179
INVOICE NUMBER FEE NAME FEE AMOUNT
04-18-352347 Pool Inspection Fee-Year Round $200.00
TOTA L PAYMENTS: 5200.011
FLI-0000187
CASE TYPE: Food& Lodging Institutions WORK CLASS: 53 -Year-Round Swimming Pool
SITE ADDRESS: 1950 13TH AV DR SE DR,HICKORY NC
Owner PIEDMONT CENTER ASSOCIATES 2258 HWY 70 SE. HICKORY NC 28602
13:8283224825
Paid By FAIRFIELD INN HICKORY LLC,2258 US HWY 70 SE. HICKORY NC 28602
**NO PEOPLESOFT ACCOUNT ASSIGNED**
Pool Operator LYNN TALLENT. 1950 13TH AVE DR SE,HICKORY NC 28602
C:8284313000
receipt (1020/2018 1121 Page 1 of 1