Tooele Health Department
             
Tooele County Health Department
151 N. Main Street, Suite 140 - Tooele, UT 84074
Phone (435) 277-2440 Fax (435)277-2444

Plan Review Application for
Electronic Smoking Device Establishment


Please put N/A for any fields that are not applicable


Owner's Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:

Establishment Name
Phone Number
Street Address
Mailing Address

PLAN REVIEW
                                                                                                                                                                               Date
                                                                                                                                                                              Received
Plan review fee, Sec. 8 Receipt#
Floors/walls/preparation surfaces/equipment shall be smooth, non-absorbent & easily cleanable
                  Sec. 5.4.2
Storage area for E-liquid and Nicotine, Sec. 5.4.2.7
Storage area for chemicals, Sec. 5.4.2.8
FORMS
Standard Operating Procedures (SOP), Sec. 5.4.3
SOP training log, Sec. 5.4.3
E-liquid documentation, Sec. 5.4.4.1.1


All of the above statements are true. I understand that any false information on this application may be cause for denial or revocation of my Electronic Smoking Devise Establishment Permit. Permits may be revoked or suspended for violation of
Tooele County Health Department Regulation #18.
Permits are non-transferable.

Applicant's Signature
Date

Electronic Smoking Device Plan Review:   $150.00   Item Subtotal:  
$150.00
Total:
$150.00
 
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Method of Payment:
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Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
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