Environmental Health Forms
We've Moved!
The Environmental Health Division is now located at 1221 W. State St., Suite B, in El Centro, CA, 92243. icphd.org/ehd-new-address
If you have any questions, please call us at 442-265-1888.
Welcome to our comprehensive collection of environmental health forms! Navigate effortlessly through the sections using the quick navigation buttons to find the form you need
Animal Adoptions
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Adoption & Low-Cost Spay Neuter Agreement
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This form allows Animal Control staff to keep records of the pets being adopted and neuter agreements in accordance with County Code. |
| Animal Adoption Policy |
Individuals who choose to adopt an animal from the county shelter must complete and agree to the terms and conditions of this form to begin the process of facilitating an adoption. |
Body Art
| Application for Body Art Facility Permit | This application is the initial form to apply for a body art facility permit. The application consists of general business information, location, and owner information, sanitary services infection prevention control plan, body art practitioners, and the applicant's certification. |
| Application for Registration of Body Art Practitioner | This application indicates the practitioner’s information, site of operation, type of body art procedures, days/hours of operation vaccines required and OSHA Bloodborne pathogens training. |
| Body Art Facility Infection Prevention and Control Plan | This form requires the facility operator to fully describe the decontamination and disinfection of ALL equipment used in the facility including the method of properly disposing used tools contaminated with bodily fluids. A sterilization log is attached to this link. |
| Health Care Professionals Hepatitis B Declination Statement | A body art facility employee who refuses to take the hepatitis vaccine signs this form. |
| Application for a Body Art Event Organizer Permit | This form provides the guidelines for such event, general event information requested, waste disposal, a list of body art booths, and a site plan. |
| Temporary Body Art Facility Application | This form requires general information about the temporary facility, disposal of instruments, booths set up, wastewater disposal and other safety questions.
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Food Facilities
| Plan Review Guide | This form is for food facility applicants to provide basic information to the division. It also provides a checklist and guidance information for applicants to be ready for their initial inspection. |
| Food Facility Health Permit Application | This application is for any food facility. The application includes the location, ownership information, management, and billing information. |
| Common Restroom Agreement | This form is an agreement for multiple food facilities to share restrooms and most importantly abide by California Health and safety Code Standards. |
| Plan Review Application for Food Facilities | This form is the initial procedure for a Food Facility. It will assist the division in evaluating the facility. |
| Flooring Examples | This form provides diagrams and information for properly installing flooring in a food facility. |
| Request for consultation | This form is used to obtain a health inspection prior to entering a contract for lease/rent a facility to obtain health inspector’s guidance as to what consumable items may be prepared and sold and/or to determine to what extent modifications must be made (e.g. sinks, approved flooring, water heater). |
| Re-Score Re-Inspection Request Form | Use this form to apply for a re-inspection or a re-score inspection. This form is also used to apply for an inspection to re-open a food facility after a failed inspection. |
Mobile Food Facilities
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This form is the initial procedure for a Mobile Food Facility. It will assist the division in evaluating the vehicle. |
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This form identifies the owner, operator, unit information, and operational information to assure there is a responsible party for the vehicle. |
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This form addresses where a food vendor will store the equipment properly and the of the facility allowing the storage of equipment. |
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This form is for facilities to grant permission to Mobile Food Facilities who are operating within 200 feet of their facility, to use the restrooms/hand washing stations. |
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| Request for consultation |
This form is used prior to purchasing a Mobile Food Facility to obtain health inspector’s guidance as to what consumable items may be prepared and sold.
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Temporary Food Facilities
| Application for Community Event Organizer Permit | This form indicates what type of event is being proposed. It also shows the contact information of the event’s responsible party. |
| Application for a Temporary Food Facility Permit | This application shows specific information about the event and lists the proposed consumable items. Staff to ensure proper Health and Safety standards for the public closely review this application.
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Cottage Food Operations
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This form includes general information about the Cottage Food Operator and a detailed questionnaire regarding kitchen sanitation requirements, food preparation/packaging/handling, and other Health and Safety standards. |
Microenterprise Home Kitchen Operations
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To initiate the review of your application to operate a food business within your residential private kitchen. Please complete and submit this form. |
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This application is for any food facility. The application includes the location, ownership information, management, and billing information. |
Land Use
| Septic System Application Form |
This form requests general applicant information, the type of septic system being proposed, the removal or abandonment septic tank if there is an existing septic tank, and the certification (signature) of the installer. |
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This application requires basic information of the applicant and the proposed project. The proposed project would be analyzed with the septic tank in place. |
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This application is used to apply for a permit to install an underground sewage-holding tank. (A sewage-holding tank does not have any leach fields.) |
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This form indicates an applicant to a septic system the requirements needed such as, soil percolation report, site plan, engineered design, and permit fee. |
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This form provides the required information on a site plan, the setbacks information, and a sketch as an example of a site plan. |
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This policy summarizes the standards and requirements that will be applicable to a leach field utilizing gravel-less chambers in Imperial County. |
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Imperial County Existing System Evaluation and Certification Policy |
This form provides the policy and procedures for the evaluation of an existing septic system when the division is unable to locate any record of its approval. This policy is mostly applicable when it is necessary to supplement information provided for a Building Plan Review Application Form. |
POE Pilot Project
Applicants
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The completion of this application is required for those eligible and interested in participating in the POE Pilot Project. |
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The completion of this form is required for POE Pilot applicants who do not own the property where the installation of a POE system will occur. Property owners must consent by signing this document prior to any sampling or installation of equipment. |
Vendors
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The vendor shall submit this form prior to the installation of a POE system. This form is used to determine the existing conditions of a property and will be used to determine what POE system components will be necessary for installation. |
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The submittal of this form by vendors is required once for the initial samples taken prior to the installation of a POE system. Laboratory sample results shall be entered into this form and submitted, in conjunction with the lab results, to the division. |
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This form is used to document the pressure, turbidity and water usage for each POE system. The form shall be filled out monthly by the vendor and shall be submitted to the division. |
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The submittal of this form by vendors will be required quarterly, and annually. Data on this form will be collected by vendors and tracked by the division throughout the life of the POE Pilot Project. |
Pools
| Pool Permit | This application is for any proposed public pool. The application includes the location, ownership information, management, and billing information. |
| Pool Plan Review | This form is utilized when submitting a pool plan review. The form has the current fees, pool facility information, billing, contractor, proposed work, and signature for agreement. |
| AB 1020 Compliance Form | This compliance form is based on the California Department of Public Health, in accordance with Health and Safety Code Section 116064.2. The form identifies the type of equipment used for pools for licensed contractors to fill out. |
Private Water Systems
| Private Potable Water Test Result Submittal Form | This form is to be completed by the person performing the sampling or by the laboratory providing the sampling service and is to be accompanied by the test results for review by the division. |
| Required Testing to Determine Water Potability | This document demonstrates the required tests needed to determine if the water, whether treated or not, meets potable water standards. The division verifies all constituents on this document are sampled and meet the standard for potability. |
Public Water Systems
| Permit Amendment Application Form | This application is used when proposing an amendment to an existing Domestic Water Supply Permit. The form contains the water system information and the proposed modification or addition to the existing water system. |
| Domestic Water Supply Application | Use this form to apply for a Domestic Water Supply Permit. The application consists of the applicant’s information and the proposed water classification (i.e. community, non-transient, transient). |
| Bacteriological Sample Siting Plan - Groundwater Systems with Continuous Disinfection | This form is for groundwater water systems with continuous disinfection to denote the sampling locations of routine, repeat, and source water bacteriological water quality samples. The form includes the system's information, the laboratory where samples are sent, the sample locations, frequency of sample collection and the person who obtains the samples. |
| Bacteriological Sample Siting Plan - Groundwater Systems | This form is for ground water systems to denote the locations of where routine and repeat bacteriological samples will be taken. The form includes the system's information, the laboratory where samples are sent, the sample locations, frequency of sample collection and the person who obtains the samples. |
| Bacteriological Sample Siting Plan - Surface Water Systems | This form is for surface water systems to denote the locations of where routine and repeat bacteriological samples will be taken. The form includes the system's information, the laboratory where samples are sent, the sample locations, frequency of sample collection and the person who obtains the samples. |
| Disinfection Byproducts (DBP) Sampling Plan | This form is the DBP monitoring plan for water systems. The form includes sampling location(s), sampling frequency, and how MCL compliance is calculated. |
| DWR - Grout Advisory | This form is to inform well drillers, local enforcing agency staff and others about important sealing material consideration for well construction (annular seals) and destruction in the unsaturated zone in accordance with the California Well Standards. |
| Emergency Notification Plan | This form is referenced when a water system has an emergency (i.e. confirmed positive bacteriological sample, water line break, loss of pressure, etc). The form contains the water system name, division staff contact information, and a proposed notification method to the water consumers. |
| Water Quality Emergency Notification Plan with Drought Planning Elements | This form is referenced when a water system has an emergency (i.e. confirmed positive bacteriological sample, water line break, loss of pressure, etc). The form contains the water system name, division staff contact information, and a proposed notification method to the water consumers. This form shall be exclusively used by school and community public water systems. |
| Lead & Copper Reporting Form | This reporting form summarizes lead and copper sampling results. The form includes the date, location and the results of the testing. This form must accompany all lead and copper sample results. |
| Lead & Copper Sampling Plan | This sample-siting plan contains the facility information, sample collection data, map of system and sample locations for lead and copper. |
| Lead & Copper Worksheet | This form is to assist the tracking of lead and copper sampling results, including sample locations, levels detected and how to calculate the 90th percentile for both lead and copper. |
| Operation Plan Guidelines | This form pertains to operation plan requirements issued by the State of California Health and Human Services. |
| State Approved Surface Water Treatment Systems | This form summarizes alternative filtration technologies that have been approved by the State for the treatment of surface water. |
| TMF Instructions | This document describes how to complete a Technical, Managerial, and Financial (TMF) Assessment form. |
| TMF Assessment Form | This form shall be filled out by all newly proposed water systems or when a water system change of ownership occurs. The form includes water system information, person completing the assessment, contact person information, consolidation feasibility, system description, certified operators, source capacity, operations plan, training, ownership, water rights, organization, emergency response plan, policies, budget projection, and budget control. |
| Water System Facility Information | This form must be completed when filing any type of water system permit. This form allows Imperial County to maintain its databases for reaching out to small water systems with important information (e.g., invoicing, notices, etc.). |
| Plan Review Application Water System | This form shall be submitted when proposing any modifications to the water supply, treatment system, storage tanks, or distribution system. |
Septage Haulers
| Operating and Permit Requirements for Septage Haulers | This form contains a list of requirements for septage haulers to be permitted to operate within Imperial County. |
| Application for Septage Hauler Permit | This application must be filled out initially and annually before a septic truck hauler inspection. It contains the operator information and vehicle information. Download application |
| This form is used to properly document the inactivation of a permitted vehicle that will no longer operate in Imperial County. |
Solid Waste
| Business Modification Form | This form is used to remove vehicles that will no longer operate. One form can be used for multiple vehicles by simply including the license plate number for each vehicle no longer in use. |
| Solid Waste Hauler Registration Form | This form must be filled out initially and annually when registering a solid waste hauler with our division. The form contains the business information, owner information, and detailed information about the truck and the capacity of the truck. |
| Solid Waste Bin Registration Form | This form must be filled out initially and annually when solid waste collection bins are to be used. The form contains the business information, owner information, and detailed information about the truck and areas of distribution. |
| County Clean-Up Assistance Program | This informational document provides the steps that are necessary in order to qualify and obtain a clean-up voucher under this county program. |
| Solid Waste Clean-Up Voucher Application | This form shall be completed once the division has approved your property for clean-up assistance in order to obtain the clean-up voucher. |
| Business Modification Form | This form is used to properly document the inactivation of a permitted vehicle that will no longer operate in Imperial County. |