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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT O <br /> 1868 E Hazellon Avenue,Stockton,California 95205.8232 d <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:v&&&jqoV.o%/ehd/unijjji.html <br /> California Environmental Reporting System Lead User Authorization Forrit t EIVED <br /> The San.Joaquin County Environmental Health Department(FHD)will be required to accept electronic data for specified <br /> CUPA programs through the California Environmental Repotting System(CERS)no later than January 1,2013. CEC 1 E 2014 <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 y'LUNlgjl (.; ENTL N A <br /> lead user must have his/her own unique email address. The operator/owner is required to file a new au"t HEALTH <br /> form when a Lead User can no longer file compliance data on behalf the business or when a new Lead User is adPARTMENT <br /> Facility Information <br /> F&dDWMB ` [Fodor c"sos ,s r mr sI�304 �u,+�- +' Akee-Ar G'- waw <br /> ` `3- �. vo ho-i MAAIV14W r_ Com- Fhono 7 �r� R <br /> Business Owner Information <br /> rhoneB fnell AtltlF.¢ <br /> Gi'� l CO �l.�I�i� • PA+��Z 5� <br /> wnree <br /> 4s9 V C4 cit t f <br /> Authorized lead Users—Designate atyleast 2 people with different email addresses <br /> ra a NFIII! rUk phom-8 Em ImdRg <br /> Acca No,c m4 Lem rhonev Qmaa Oda,¢:6 <br /> 1f�1 cS'fir7kata. OS CJa Sp1I D <br /> ane rim thoneB Elwu ms Cc-h aD ��rh <br /> If you own/operate multiple facilities within the San Joaquin County(and not elsewhere in the state)and wou like the Cfi <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 /> NEL%y 10 Frarinn PBA uolrcvs <br /> ioGBtY OF4 C 100 [MA <br /> A —�— moos <br /> FRlIIry IPp C£a$IPB p,ip,dy <br /> FyHM1y IPo QRf 1➢e A <br /> Certification—I certify that I am the owner/operator or legal repreuntative of each facility listed on this form. 1 understand that <br /> compliance dxuments submitted electronically by authorized users risted on this form imply certification by the owner/operator <br /> of the truth and accuracy of the submitted Information in acoMilance with lowl,state and federal law. <br /> symmn ofvwner/oFerater oFupin PF4rnHea BnresenlaeE,. erh,gd.*.. nB. <br /> �iwkuru e- g wN <br /> Name eFPomnrm am <br />