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HomeMy WebLinkAboutHoliday Inn Express and Suites App 500071 04 21 11.tif F� '• �Niay il �iJll �:31PN'i Holicia.y Inn 'r'�� �Pdo.3�i3b i%� �, �r� v �r� ��"� N.C,. Deparnnent of Environment arul Nanii�al Resources . , : = � , .: : . _ _� Divisian of Environmental Health p�, ��� ���/5 �QO� f _ - . APPLICATION FOR �USLIC SWIti1h�T�G �O�L �P�,,��'I�N JPEi�f[� :, --- ....._ .. ... ._ ._ .. ` - IPOOL INk'O�t11�(ATION: � _. � , /1 /, � �` <" —r � " ` Name of ublic swiauni �cc� � � _ - �� '�, -, � p ,��,,. J . ... L.� �: - _ _ _ , �., - - � -� „ L , ` y . . . _ ... � �/ '' L r�/" � �� L.'. ,.%� i v i� vl i ��- . , ii � . ....."'_'_ '_"..... ... _... _....... . � � , „ . / . �. '_"_'... .." / -..l_ :...:...... . . .'.;_ .,.... . . . / % .� . ., � ' n . - Sueec address of pool location: � /G' � t � _ .... . . _ . .. . ---_......... � _ .. Ci � �`, •� �r l.ull� y r ; r i ,.. ty . , J � -, , . , - � •�r�: �: . � .. � �- �,. ,: r 3 '— -_—. ..:_. ._.... '�' - - T..ype.of public.s.wi�riunin ool: (check one ,, _.._. .. . _ � P ) �� S�vunming pool i I `�'�;1Cut�� � �r� I . I (lrh.,. i.7,,..,•,;h�l � ,_.... _.--------.__........-•--•...._....._.... ,.. � ...�...., �..� D3ro ��„��..,,. �d ?r ren�cc�o,o��. �H� ..,, _ . ,- u �- -- - , �, - __ _ ,., ...,,c :. , ..__ --- _.. .. _. _ . . : ,.. . . , ...: ., . .. . . , , .. . _ --. . . ...... .. ............ .. ._... , . -a` � U ti�.�!% !.] yy_� or later : . _ _:..__ :.._� ,. , , .�. :_:_ . >:_--:.__ --- : . -� � -- ati�t�t - _ . op�ning date �''�i - >` �% ` � closin? date % �' ' � ✓ �- � r Hours.of operatior_: op°nir.g tir�� � ' �'�v �?-;,"`- � • • ��� • ,. �';,--� - --- - �--- - _ .., , �i0ou;� wi�� ' c. , c: .� � .. ... . ,.. .. . :,_r OW -- =-- � .._....... .... __ " Naz}�e of owner:�.. ��%Y c j ��� �� I-�-b✓� ._ ; . ___ _ .-•-__ , ....M&i111]g �ddres5: / ,'� - T - � � .l.a, � :D i� �1�� �--= '. -F �- � � j� �. l��' L- 7 � <�� � .,.:. ......._ . Contact person: �� s ; � -� /L"�� .0 ( e r Telephone: �, 7?'-� �/,: S- �� "r � . : � . OP�RATOIt (On-Sxte Mana�er) INFORMATION: � _..._. ....._ :�:; .. �ame of po�l operacor: � ��� 1..� �. ��,�� .�.... , qddress: j � `� � 1..� �`+, `�'r S�v �� 1 �^= �f � ' � � I 1-•-� ^.; C Z ;� (� ;, I — ---... .___.. ._ .... ... _ ..... ..._ :.- , Telephone Number: �� C� I c_: - Z 2 i,� � Fool .o . erator trained 'o ' ' ' � / ' ' ,...,,...., . p y: (cneac one� U �iacional �wvnm�ng Pocl Foundacion (Certif cate Number: ��� C � Q Z- �� b�j6o � --�-----•�-------- _--�-----��-----._..._....... —. _ .. . ... . . . .. . ❑ Other (please specrfj+J _ APPI.ICATION SiJBNI�TT�;D BY: , .'/ �, : ; . ., .. . . ; , . / L(7I`.. �%"r:� (��>��� �� �,v"J (�� 1.._.� �:` I ���,., —. ......._..... .. ,: . 'Q�JEI'g ^"�_----� . Sl�l"�.�(IlllTf � Typed or printeri nnjrte ,:........_.._ .. lDate � � Y�- z i-� 1 �_ _...--- �--....... __.----.—.. -� Purp�r St�tutt.l3U,?.-237�tequirr.s thq Cemmi:siun Ior Healch S¢n•icas to adopt rules p,oveming public sµlmminy pQ�(„ 'rne rulzs in t�A �:. NC�AC 13A .250U requir¢ t6e�owner or operator to apply annu�lly for an operation pernit for :ach puhGc r.�-imminy pool. This fum� is to �llo:!� "_..' . . - • - "�SG�'or`o cTato'rs of" u�c swirtimin p p g pools W appiy fur permi�. Preparalion: The inforrrtaunn rcqucstcd on �his ferm i: to be eompleted by thc —"'-'-"-'° "�" Nwi uw�iv.ur a�v�igftffiEa irHT£c8ttfa[i� �i inc owncr. inc wmplciai cippiicauetl ic suomia�i co Ine locs neaith �epartmcn[ tnr u�c countv i� wnicn —....:. fhe ublie, swimmin oal �s located. A sc srate a licalion m�se he com leced for each ubGe swimmin 'c�:; . p � p p pp p p g pool. Cupies: Ori�inal rp he maintaineA at �.—.---,.._ _. ..�elocdl_6e.�ilihdepertrr�cnt..nisposition, PI¢asc tcfr� to Records Fetention an� Disposition Schedule for CounryrDistr�ct Heal�h Depanments �--••�•- •�-� •wFiich-are-published by ihe Nor[h Catolina Division of Historical Reiources. Reordcr Additicnal forms msy be orAe.red (rum� Division ef - Environmr.nlal He:�lh, Departmrnt Uf �nvupnmcnt and tJatural Rcour«s, 163� Mail Scrvi�c Cenler, Fsleiglt, NC 2%699-163Z, (Ceuricr S2-e)1 �l(?j _ DENR 3967 (Revised d103) �� % � - 1 -/ ' � ��/ _.. Enyironmantal Health Services Section (Rcv�cw 4I06) r7yt �.�� ���- y Y6- �f��