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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Avenue,Stockton,California 95205-6232 J <br /> Telephone:(209)4683420 Fax:(209)4683433 Web:www.sirtov omlehdlunifiif.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 forspeciried <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 END to create, edit, and <br /> submit electronic data an the owners 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 /> (.mt/0/ kt;' <br /> AddRL / 33 rr,on. <br /> atit.Tec� <br /> Business Owner Information _ <br /> VE—ukIII CDP <br /> AMOM ••(/ <br /> 4S5` Cf e of <br /> Authorized Lead Users—Designate a east2 people with different email addresses <br /> d N M ny, 9bMr un,n Addrm <br /> Doers 6 „�.0 a Mti"a' �L_� LWA <br /> Add ( <br /> SNS D <br /> vn. n,y rnoMr cm.uy�m a„h OO.G2Yvt <br /> Ad ep(.�t�er <br /> 0 ea <br /> If you own/operate multiple facilities within the San Joaquin County(and not elsewhere in the state)and wets like the <br /> lead authorized users listed above to have access and authorization for the other facilities, provide the Information <br /> below. <br /> Additional FacilitieslnSanJoa uinCounty—attach additional sheet if necessary <br /> (,tlRrOr CpUiDr DM lddrn, <br /> A.DryOr (an1DI DRA Add,., <br /> 7,Wry,er QRrlOt <br /> 08A )ddro, <br /> r,Wry01 QRtlor DeA Adam, <br /> eertination-1 certlfy 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 certillatlon by the owner/operator <br /> _ of the truth and accuracy of the submitted Information In accordance with local,state and federal law. <br /> MNOM/prO+.'nt,(OrglWOf lte,llr D„Ijn,W ll.pnMn4,fn �N..µuN � <br /> Num pl Dpamtq puc / '• WL <br /> 4 <br />