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verify that I am the ownerrhorne 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-0 of the California Health and Safety Code. <br />Print narne Atc7'/2( <br />S gnature <br />Address /‘, / 12)-65 A y <br />C tty /6s st Zip 75.241Z) <br />Telephone ( 702 7 <br />0 There is no pool light in this/these pool(s). Indicating there Is no pool light 02,911.1 there <br />no light fixture, light casing or recessed light niche, whether working or not <br />working, within the confines of the pool shell. <br />Date <br />Site address of pool(s) • il/a t7 <br />c,ty <br />Number of swimming pools, spa pools, wading pools or special purpose pools at the site <br />41/11 <br />Sep-15-99 03,.21P Po' <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />104 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-1420 <br />VERIFICATION OF COMPLIANCE WITH CALIFORNIA HEALTH AND <br />SAFETY CODE, SECTION 116049.1 (a-f) <br />Please attach a copy of the completed and signed inspection permit or report from the local <br />building department and send tor <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 />_ <br />15.* c"?±' 5- tekto.tcm,,sc,;e1 <br />o <br />1 <br />Ro, • f lei <br />Co <br />X <br />Post-it Fax Note <br />7071 <br />ri° <br />Gc.,Deot. <br />ARortel <br />Li4-g3q <br />: LAO'd : 'ON 3N0Hd E:c1 14022:t0 6661 ST 'ciS