San Juan County Public Health
             
San Juan County Health Department
735 S 200 W Suite 2, Blanding, UT 84511
Phone: (435) 587-3838

Tobacco Fine for Sale to a Minor

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

Date
Owner Name
Contact Phone Number
Contact person if different than owner
 
Fine Amount:   $500.00   Item Subtotal:  
$500.00
Total:
$500.00
 
Payment Information:
Processing Fee Rates:
Cards: 2.5% ($1.50 min)
(4% for foreign cards)
eCheck (ACH): $0.75
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:
 Change Payment Method
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