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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
eh@TooeleCo.gov
Application For Decontamination of Chemically Contaminated Property Permit
Please put N/A for any fields that are not applicable
Decontamination Company:
Name
DEQ Certification Number
Address
Telephone Number
Email Address
If you have additional documents to send, please email them to
eh@tooeleco.gov
.
Property to be decontaminated:
Address
Owner
Owner's Phone Number
Owner's Address
Permit Fee:
$350.00
Item Subtotal:
$350.00
Total:
$350.00
Applicant's E-Signature
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
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Name
is required
DEQ Certification Number
is required
Address
is required
Telephone Number
is required
Email Address
is required
Address
is required
Owner
is required
Owner's Phone Number
is required
Owner's Address
is required
Applicant's E-Signature
is required
Date
is required
You must enter a payment method.
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