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Date -7 - Print name <br />"F <br />Signature our <br />Address <br />City <br />Telephone ( ) Y„.2.3 - <br />PUBLIC HEALTH SERVICES <br />' SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />VERIFICATION OF COMPLIANCE WITH CALIFORNIA HEALTH AND <br />SAFETY CODE, SECTION 116049.1 (a-f) <br />Site address of pool(s) Li 70 Ito (44, <br />City 7-Y) (4-)d4o Cex q 5 5 34 <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />( r <br />I verify that I am the owner/home owner association president/legally responsible person for the <br />above named pool(s) and that I had the pool(s) inspected for compliance with Section 116049.1 <br />(a-f) of the California Health and Safe ;y Code. <br />There is no po91 VA in thWthese nool(s). Indicatin5there is no nool light means there <br />is no light fixture, light casing, or recessed light niche, whether working or not <br />working, within the confines of the pool shell. <br />Please attach a copy of the completed and signed inspection permit or report from the local <br />building department and send to: <br />San Joaquin County <br />Public Health Services <br />Environmental Health Division <br />Recreational Health Program <br />304 East Weber Avenue, Third Floor <br />Stockton, CA 95202 <br />A Division of San Joaquin Count:v Health Care Services