HomeMy WebLinkAboutLa Quinta Pool App 500096 03 25 11.pdf � �ti
N.C. Department of Environment and Natural Resources
Division of Environmental Health -j11� �� f$ J-r'�D�C��
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APPLICATION FOR PUBLIC SWIlVIMING POOL OPERATION PERMIT
POOL INFORMATION: �L �•� j�� (,o3�f Q
Name of public swimming pool: L-� �I �tii��i �r1 n �� ,� 1.�i ���5
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Street address of pool location: r C�J ] � I"C�1 f'ti '� �r�. ��
City: (� N�Y County: ��i.�ct,L�` (; G
Type of public swunming pool: (check one) � Swunming pool
❑ Wading pool
❑ Spa
❑ Other (describe)
Date constructed or remodeled: (check one) ❑ Before May 1, 1993
❑ May 1, 1993 or later
Dates of operation: opening date I I � closing date f� � S� � �
Hours of operation: opening time i 0 A,� closing time 1 � �� f'Yl
OWNER INFORMATION
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Name of owner: ��GOC�I ���)( �� � .� �L� �L� �1,�'U �i�h � Si,u�� �
Mailing address: /�(7 , ��tt v� -v�v r �,�t�Uy�� ��a� Cnr�o-�/c�r N�L , `L��� 1 '�
Contact person: iiG h /�c,�.{`�� Telephone: `�21? � SI �� r3 3 S
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: �ct C'�c �� C�,�'t��71'I C(� _
Address: ��G� �1 [ j�� ��noVc1'� l� � , �6l �i
Telephone Number: �� Z. =? - �i' � S l/� C�
Pool operator trained by: (check one) �� National Swunming Pool Foundation
C ����.� �' � �m i v�y �c; � � � S ('`j (Certificate Number: �;���J l - � � )
/.� S�cac�,{�'��,�t � ❑ Other (please specify)
APPLICATION SUBMITTED BY•
Owner or operator: � �'" ``� rC� ���U �/��� �--
Signature Typed or printed name
Date_: � � 2 S� f l
Purpose: General Statute 130A-282 requ'ves the Commission for Health Services to adopt rules goveming public swimming pools. The rules in 15A
NCAC 18A .2500 require the owner or operator to apply annually for an operation permit for each pubGc swimming pool. This fortn 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 nepresentative of the owner. The completed application is submitted to the local health department for the county in which
the public swimming pool is bcated. A separate application must be completed for each pubGc swimming pool. Copies: Original to be maintained at
the local health departme�t. Disposition: Please refer to Records Retention and Disposition Schedule for Counry/District Health Departments
which aze published by the North Cazolina Division of Historical Resources. Reorder: Additional forms may be ordered from: Division of
Environmental Health, Department oFEmironment 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) ` " o "` /
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.���'��'�O� CATAWBA COUNTY, NC
� ,� 100-A South Wesc Blvd PERM/ T RECE/PT
Newton, NC 28658-
� ,�<; �`.- ,�, Phone: (828)465 8399 Friday, March 25, 2011
I I8 42 SM www.catawbacountync.gov
Permit Number: FLI-3-11-16380 Invoice Number: FLI-3-11-273415
Permit Type: Food & Lodging Institutions
Work Class: 50 - Seasonal Swim►ning Pool Receipt Number:
Site Address: 1607 SE FAIRGROVE CHURCH RD, Conover, NC
APPLICANT OWNER
LAQUINTA INN GLOBAL HOSPITALITY 111 LLC
1607 FAIRGROVE CHURCH RD PO BOX 1022
CONOVER NC 28613- CONOVER NC 28613
(828)514-1335
FEES
FEE DESCRIPTION DATE FEE AMOUNT
Pool Inspection Fee 03/25/201 1 �150.00
TOTAL FEES $150.00
PAYMENTS
PAYER: GLOBAL HOSPITAL III LLC
GLO H III LL
Date Payment Type Check Number Amount Change
03/25/2011 Check 2469 $150.00 $0.00
Memo: NCDL34941957 GXP 1I/23/I6 DOE3 I I/23/80
Total Payment: $150.00
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