Delivery of Inspection Reports Pursuant to A.R.S. § 41-1009, the Department may enter your establishment to conduct inspections. You have the right to receive a
copy of the Department's inspection report at the time of the inspection, within thirty (30) days after the inspection, or as otherwise provided by federal law. I agree
that the Department may send me a copy of its inspection report by e-mail or by facsimile transmission to the e-mail or fax number provided under the Business
Ownership Information provided above. It is the responsibility of the permit holder to update the Department if there is a change in contact information.
I hereby certify that the above information is correct, agree to comply with the Maricopa County Environmental Health Code, agree to allow the regulatory authority
access to the establishment as specified under § 8-402.11 and to the records specified under §§ 3-203.12 and 5-205.13 and Subparagraph 8-201.14(D)(6), and I fully
understand that any deviation from the above without prior permission from the Maricopa County Environmental Services Department may nullify final approval.
Disclaimer
Information entered on this form will be retained by Maricopa Environmental Services Department and is a record as defined by Arizona law.
This form will be provided without redaction in response to a public record request unless any of the information is exempt from release under Arizona law.
By checking the check box and typing your name you have digitally signed this application.
Signature: Date:
I agree the application is true and correct.
Arizona law, A.R.S. § 11-1605(I), allows Maricopa County Environmental Services Department (MCESD) and the applicant for a license to mutually agree to extend the plan
review time frame by 50 percent of the substantive time frame and overall time frame. MCESD will agree to any applicant's request for an 50 percent extension of the substantive
review time frame and overall time frame when box is checked and signed below.
Signature: Date:
I agree to the 50% extension.
Make checks payable to MCESD. We also accept Visa, Mastercard, American Express and Discover.
If submitting application electronically, payment can be made via online once the application is accepted and reviewed.
Pg. 3
Fees (office use only)
Application Type Plan Review
Expedite Plan
Review
# of Machines
Annual Permit
Fee
Permit #
Vending Machine Plan Review (machines
not certified by NAMA only)
$615 $1230 $220/year
Vending Machines (certified by NAMA) N/A N/A $220/year
