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:/ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Avenue,Stockton,California 952058232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov ora/ehd/unidil hlml <br /> California Environmental Reporting System Lead User Authorization Form <br /> The San Joaquin County Environmental Health Department(END)will be required to accept electronic data for specified <br /> CUPA programs through the California Environmental Reporting System(CERS)no later than January 1,2013. <br /> To ensure that only individuals designated by the facility owner/operator are authorized by EHD to create, edit, and <br /> submit electronic data on the owner's behalf to CERS,please designate at least two(2)lead users for your facility. Each <br /> lead user must have his/her own unique email address. The operator/owner is required to file a new authorization <br /> form when a Lead User can no longer file compliance data on behalf the business or when a new Lead User is added. <br /> Facility Information <br /> sos ►si ro�lsz � <br /> WeAr' ",✓ <br /> Addaaia eJ . `/O c--e A-t i �_4 atit,T.e_ca� C,h— <br /> T <br /> Business Owner Information <br /> B.m. u- sc--5�zw <br /> IFA Cv Ph.M. B/.�i3' Email raaa�{L Sbc <br /> 6r' <br /> aa.Nf< <br /> RS`t Cf sue a `l <br /> Authorized Lead Users-Designate at east 2 people with different email addresses <br /> d Nama Iflp Ph...Y Mae Mara. <br /> Ddeee aA.- M 3. �,L_oS�_ rEt�u <br /> Md Nam .�, Phon Y Finaa AddressSt/✓la0taa IDS CJNS D <br /> Add NameTIM Pfix-9 E,mll/ddress e- pa•�fa�_ <br /> Delete (/tea <br /> If you own/operate multiple facilities within the San Joaquin County(and not elsewhere in the state)and would like the <br /> lead authorized users listed above to have access and authorization for the other facilities, provide the information <br /> below. <br /> Additional Facilities In San Joa uin County-attach additional sheet if necessary <br /> N<YRy IOY QIISIotl OBR Addr. <br /> Puaily NY CFAdlatl DBP Adams <br /> ra<Wrylat CFln latl 08A Mamaa <br /> P.rauymtl CPadIDY DBA Add—, <br /> certification-I certify that I am the owner/operator or legal representative of each facility listed an this form. I understand that <br /> compliance documents submitted electronically by authorized users listed on this form imply certification by the owner/operator <br /> of the truth and accuracy of the submitted information in accordance with local,state and federal law. <br /> splepmaowam/oPma<ar.r F.r+w a.natatae aap.aaenuuve PmUdNam. // rap <br /> f7f%_tt OU <br /> Nameapammem PrePa.m D°t° <br /> REC 111100,r% <br /> ENN®5 <br />