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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
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
If you have additional documents to send, please email them to eh@tooelehealth.org.
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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