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SAN JOAQUIN COUNTY <br /> ENYIRONMEtdrAL HEALTH DEPARTMENT <br /> 1668 E Hazelton Avenue,Stockton,California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieoy orgtehdlunitifi.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(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 /> r.mhmr {J I "AS <br /> 505 ►s I !���z-�� � <br /> Aberd � O 33 r"°^• <br /> �• ��� 1Y s` ` dtiL�Pc�+ C k `I��L3•`t <br /> Business Owner Information <br /> _ '! GL+ prion.. un,vua.m <br /> Irlw e u�N COP �1.`i3 �rz9 56� L, <br /> AdDntf f <br /> Authorized Lead Users—Designate affeast 2 people with different email addresses <br /> nu. ?N.9 rm,auam <br /> MUM <br /> o. no. rAon.e rm,uuero, <br /> • Add <br /> JNI�t-t0. � � IDS CVNS� D <br /> ,m, nw rnon.e rm+u •cup hGa•C_.Z.1" gID <br /> o; <br /> Ad a <br /> y e �Dc p( �0er l+ 3 � z u r='ta <br /> If you own/operate multiple facilities within the San Joaquin County(and not elsewhere in the state)and wou like the Efi <br /> lead authorized users listed above to have access and allthGfilatlon for the other facilities, provide the information <br /> below. <br /> Additional Facilities In San Joa uinCoun —attach additional sheet iFnecessary <br /> TnOrrml aA11Or ODA Aadnn <br /> 1"MI De C55-10# ODA <br /> r. MMI auto I ODA aeen,. <br /> ftNrrm. a11S1Or DDA • AOeroe <br /> Certification—I cerdfy that t am the owner/opentor or legal representative of each facility listed on this form. 1 understand that <br /> compliance documents submitted electronically by outhorlaed users listed on this form imply certification by the owner/opentor <br /> of the truth and accuracy of the submitted Information in accordance with local,state and federal law. <br /> 54+.Nnor owwl0penrpr or t.r.DpONO+,W D,proenutAv hnhd N,m. raw <br /> �ran�unt� � oW gwj <br /> N,m.or aoammr pva l � ort. <br />