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Site address of pool(s) <br />City <br />Number of swimming pools, spa pools, wadiug.pLls or special purpose pool; at the site <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-0 of the alifornia I Iealth and Safety Code. <br />hint name <br />Signature <br />Address <br />City \\._ <br />Telephone <br /> Date LP <br />There. is no pool light in this/these pool(s) Indicating there is no pool light means there <br />is no light fixture, light casing, or recessed light niche, whether working or not <br />working, within the con MKS of the pool shell. <br />JUN-09-99 01:58 PM TRACYPARKAPARTME 12098361462 <br />PUBLIC HEALTH SERVICES <br />SAN JOAQUIN couvry 4V '71 <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., MAIL, Health Officer Pr. <br />304 Last Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />VERIFICATION OF COMPLIANCE WITH CALIFORNIA IIEALTH AND <br />SAFETY CODE, SECTION 116049.1 (a-II) <br />Please attach a copy of the completed and signed inspection permit or report from the local <br />building department or the qualified contractor 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 irlVitittlil Ut S.111 10.1l111111 Cl)11111y 114:01111 Care Service,'