SAN DIEGO STATE UNIVERSITY
ENVIRONMENTAL HEALTH AND SAFETY DEPARTMENT
FOOD SERVICE FACILITY
PLAN REVIEW APPLICATION
(For Office use only)
INTAKE DATE:
NEW/TI
REMODEL
CONVERSION
OTHER:
Projected Date for Start of Construction/Renovation/Conversion:
Projected Date for Completion of Project:
Name of Food Service Facility:
Facility Address:
Total Square Feet:
Phone:
Business Owner Name:
Company:
Contact Person Name and Information (phone and email):
Architect Name and Company:
Contact Person Name and Information (phone and email):
Food Designer Name and Company:
Contact Person Name and Information (phone and email):
General Contractor Name and Company:
Contact Person Name and Information (phone and email):
Operator Name:
Company:
Contact Person Name and Information (phone and email):
Type of Foodservice: (check all that apply)
Unpackaged Food Prep
Limited Food Prep
100% Prepackaged
Type of Food Service Operation: (check all that apply)
Permanent Food Facility -
Kitchen
Catering
Cafeteria
Fast Food/Quick Serve
Bar
Convenient Store
Concession Stand
Buffet/Salad Bar
Bakery
Action Station
Mobile Food Facility (supplemental form may be required)
Mobile Support Unit (supplemental form may be required)
Certified Farmer’s Market (supplemental form may be required)
Temporary Food Facility (supplemental form may be required)
Commissary
Vending Machine (only applicable for potentially hazardous foods such as sandwiches, milk, etc.)
Child Care Facility
Type of Food Service (check all that applies):
Prepares, offers for sale, or serves POTENTIALLY HAZARDOUS FOOD
Only to order upon a consumer’s request
Revised 03/2012
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In advance, in quantities based on projected consumer demand and discards FOOD that is not
sold or served by a specified time
Using time as a public health control (requires EHS approval)
Prepares POTENTIALLY HAZARDOUS FOOD in advance, using FOOD preparation method that
involves two or more steps which may include combining potentially hazardous ingredients: cooking;
cooling; reheating; hot or cold holding; freeezing; or thawing.
Prepares FOOD for delivery to and consumption at a location off the PREMISES of the FOOD
ESTABLISHMENT where it is prepared. (i.e.-a catering kitchen)
Prepares only FOOD that is not POTENTIALLY HAZARDOUS (i.e.-a concession stand)
Does not prepare, but offers for sale only PRE-PACKAGED FOOD that is not POTENTIALLY
HAZARDOUS
Prepares FOOD to a HIGHLY SUSCEPTIBLE POPULATION. (i.e.-a child care center)
Food Facility
Kitchen, Storage, and Food Prep Area (sq.ft):
Dry Storage Area (sq. ft):
Utensils/Equipment Used?
Yes No
Customer Utensils?
Single Use Multi-Use
Will alcohol be served and consumed on site?
Yes No
Will dedicated employee TOILET ROOMS be provided?
Yes No Location:
Will consumer TOILET ROOMS be provided?
Yes No
 If yes, are separate men’s and women’s TOILET ROOMS provided?
Yes No
Are employees expected to change into their work uniform in the food facility?
Yes No
 If yes, are dressing rooms provided for employees to use?
Yes No
If an exhaust hood will be used, is the hood custom made or UL listed?
Custom UL Other
 Complete and submit Commercial Exhaust Hoods and Ducts Data Information Sheet
If a grease trap/interceptor is provided, has a FEWD Plan Check Application been submitted to the City
of San Diego?
Yes No
 If yes, submit copy of FEWD Plan Check Application to EHS.
 If no, EHS plan review approval cannot proceed.
Identify the municipal water district:
Identify the municipal wastewater district:
In addition to this application form, applicant must also submit the FOOD FACILITY PLAN
REVIEW SUBMITTAL CHECKLIST FORM.
I declare the description of use and information contained on this application and plans are correct and
true. I hereby consent to all necessary inspections as part of this review and the operation of this
business pursuant to the SDSU Food Safety Program requirements. I also agree to conform to all
conditions, orders, and directions pursuant to the California Food Code.
Applicant Signature:
Date:
Print Name and Title:
(For office use only)
Plan Review Status:
Approved
Conditionally Approved
Rejected
Registered Environmental Health Specialist Signature:
Plan Recheck Status:
Approved
Conditionally Approved
Registered Environmental Health Specialist Signature:
Revised 03/2012
Date:
Rejected
Date:
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Revised 03/2012
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