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

Electronic Smoking Device Facility Permit Application


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

Establishment Information
Organization Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:

Invoice/Mailing Address (If Different)
Contact Name
Email Address
Street Address/P.O. Box/City/State/Zip Code

Name of Property Owner
Phone Number
Street Address
Mailing Address
Applicant is
If partnership, list name and address of each partner
Hours of operation


Requested permit will be issued only after a satisfactory pre-opening inspection has been conducted and the required permit fee has been received. Operating an Electronic Smoking Device establishment prior to permit issuance, other than during an authorized renewal procedure, is a Class B Misdemeanor. Applicant agrees that maintenance of a health permit is predicted on compliance with the Tooele County Health Regulation on Electronic Smoking Device Facilities.
This permit is revocable for non-compliance and is non-transferable,
Permit is valid for one year from date of issue.

Signature of Applicant
Title
Date

Electronic Smoking Device Facility Permit (Annual):   $   Item Subtotal:  
$100.00
Total:
$100.00
Payment Information:
Method of Payment:
 Update Name from Personal/Organizational Information
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
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