Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E Hazelton Avenue,Stockton,California 95205-6232 <br /> refophono:(209)468-3420 fax:(209)4683433 Web:www sieov orafehd/unib 1.html <br /> California Environmental Reporting System Lead User Authorization Form <br /> The San Joaquin County Environmental Health Department(EHD)will be required to accept electronic data for specified <br /> CUPA programs through the California Environmental Reporting System(CELLS)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 ownees 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 J�, »+) n, '/ //[J (/ <br /> f•cQryPL y., Ci0.f ID• DLA 1.�'v,� �C.N e: " �Y•+".Y' <br /> mos ►s r ro►�z�� � <br /> � <br /> AlQRG . � • l�US,E}yt.L /4�s"-'` JrlRtit'f•e..G.�t �A, `1�Prz3• <br /> Business Owner Information _ <br /> x.�. �i-1 �rPZR Sb c L <br /> bLru �,J <br /> q�g CJS `' � of `l�'� • <br /> Authorized Lead Users—Designate a east 2 people with different email addresses <br /> wn,• nw FW.. s„ns aea.m <br /> moi« 6�U .� M�Q� 3. >✓L_O ao � <br /> • N,rtu nc• rnon.. — Em•ObMn <br /> Da.de /✓/�rlA � I QS �NS fl <br /> Ny nw rMML rm•a ms Q-h Gfr).CYt /}r�/�,r�.+� <br /> tGkte <br /> Vxe 3 2 lots <br /> J1 tzJ� <br /> Ifyou own/operate multiple facilities within the San Joaquin County(and not elsewhere in the state)and v like the cr <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 Jea uln County—attach additional sheet if necessary <br /> f,rLrtt loL QAIDL DLA 1dll•fl <br /> .—(= R1J Io/ Du Pdar0• <br /> I.Wtt IDL GI Rf IDI OM AGlMI <br /> pWtr IDI CDG IDI DLA blmf <br /> fe nification—I certffy that i am the owner/operator or legal representative of each facility listed on this form. l understand that <br /> compliance documents submitted electronically by authorized users listed on this forth imply certification by the owner/operator <br /> of the truth and accuracy of the submined Information in accordance with local,state and federal law. <br /> SIaMdG of Dy*C!➢rn•Gr at l•anDrDWLn•W L•er•unnD,• rrrnQµC1N �w°7)v"1 net a W/U'P/t <br /> HUM DIDawm•nl prtet / � D,G <br />