APPLICATION/RENEWAL TO OPERATE A PUBLIC POOL OR SPA
Name of Establishment where pool or spa is located ___________________________________
Address ______________________________________________________________________
Name of Owner ________________________________ Phone No. _____________________
Mailing Address of Owner ________________________________________________________
Manager (if not owner) __________________________ Phone No. _____________________
Address of Manager _____________________________________________________________
________________________________________________
Signature Date
(FOR OFFICE USE ONLY)
[1] Existing Establishment ( ) [2] Change of Ownership ( )
[3] New Business ( ) Eff. Date of Change _____________
Date to Open ____________ Former Name __________________
New Owner ___________________
COUNTY OF LAKE
HEALTH SERVICES DEPARTMENT
Division of Environmental Health
922 Bevins Court
Lakeport, CA 95453-9739
Telephone 707/ 263-1164
Lower Lake Office
Telephone 707/ 994-2257
* Please make any applicable changes on
renewal application.
