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San Bernardino County Food Facility Plan Review Application

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San Bernardino County Food Facility Plan Review Application Powered By Docstoc
					                                APPLICATION FOR FOOD FACILITY PLAN REVIEW
                                 COUNTY OF SAN BERNARDINO – DEPARTMENT OF PUBLIC HEALTH
                                        DIVISION OF ENVIRONMENTAL HEALTH SERVICES
                                                     PHONE: (800) 442-2283
                                                    www.sbcounty.gov/dehs

Facility Name: _________________________________________ Phone: ________________________________________

Facility Owner: _________________________________________ Phone: ________________________________________

Facility Address: _______________________________________________________________________________________

Requestor/Contact Person: ________________________________ Phone: ________________________________________

Requestor Facility Name: _________________________________ Phone: ________________________________________

Address: ______________________________________________ Email: _________________________________________

Check Most Appropriate:         Operator            Contractor/Architect          Designer

Type of Facility:      Retail      Wholesale-Distributor       Wholesale-Processor       Wholesale-Salvager        Commissary

Basic Facility Information:     New         Existing Food Facility    Former Facility Name: ______________________________

Scope of Remodel: ______________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Nature of Service: Provide a description of the basic type of food and beverage service and nature of operation.

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Seating Capacity: ______________ Square Footage: _______________ Max Number of Employees Per Shift: ____________

                                   OFFICE USE ONLY - DO NOT WRITE BELOW THIS LINE


Received By: ____________________________________
                                                                              Date Service Completed: _____________________
Date: ___________________________________________
                                                                              DIST: ____________ City Code: ______________
    PRELIMINARY REJECT
                                                                              Amt. Paid: ___________ Receipt #:_____________
    NOT APPROVED, PLANS ARE REJECTED AS SUBMITTED                             Check #:__________________________________
    Three (3) corrected and detailed copies of the plans, including
    equipment layout sheets, are to be resubmitted for approval by            APN: _____________________________________
    this Division prior to building permit issuance. Return one
    copy of the rejected plans.                                               SR#:_____________________________________

    PLANS APPROVED AS CORRECTED                                               FA#:______________________________________
    The violations listed require correction prior to issuance of a
    permit to operate. Plans are valid for up to 2 years from this date,      PE#:_____________________________________
    after which plans are void.
                                                                              Client Contacted: ___________________________
Plans checked by: _______________________________________
                                                                              Date Client Called: __________________________
Date: _____________________ Phone: ______________________

                                                                                                                         8/6/12

				
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