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Tooele County Health Department
151 N. Main Street, Suite 140 - Tooele, UT 84074
Phone (435) 277-2440 Fax (435) 277-2444
www.tooelehealth.org
Application for Resident Care Facility Inspection
*Completed application and fee of $50.00 must be received before an inspection will be scheduled.
Please put N/A for any fields that are not applicable
Applicant's Information
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
If you have additional documents to send, please email them to
eh@tooeleco.gov.
Child Care Food Service Inspection:
$50.00
Item Subtotal:
$50.00
Total:
$50.00
*Inspection is by appointment only. Please allow up to 5 (five) business days for completion of inspection.
Signature of Applicant
Date
'Please Select Method of Payment to Continue'
Payment Information:
Method of Payment:
Credit/Debit Card
eCheck
Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
Payment method will be collected on external device
Change Payment Method
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