HomeMy WebLinkAboutQuality Suites App 500001 05 07 09.JH.pdfN.C. Department of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool:
Street address of pool location: 1125 13t4 At, b v 5L
City: d'c f on
Type of public swimming pool: (check one) M
Date constructed or remodeled: (check one) [✓J
County: Cain w L
Swimming pool
Wading pool
Spa
Other (describe)
Before May 1, 1993
May 1, 1993 or later
Dates of operation: opening date A a 2 00q closing date OL& 3 2QO
pD~1k'I
Hours of operation: opening time R` closing time I o:00 'ON
OWNER INFORMATION
Name of owner: HOsp, 4v Cr►-~up /~'~clna~e.,hc>+{
Mailing address: 1125 13 f))~//tvt Q r S ~r~,~a
Contact person: ~awre'h Cf_ nef~fc:r Telephone: V 2T S 23 -
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: Mari 41ssk I a
Address:
Telephone Number: S Zf- 3 2 3 - 12 11
Pool operator trained by: (check one) FO National Swimming Pool Foundation
(Certificate Number: 0'7 A' CA 0 2 0 3,0 ~)005'
❑ Other (please specify)
APPLICATION SUB TED BY-
Owner or operator: kwrekce !1"eW
Signature Typed or printed name
Date 5-7-o47
Purpose: General Statute 130A-282 requires the Commission for Health Services to adopt rules governing public swimming pools. The rules in 15A
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 the 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)
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