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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax.,(209)468-3433 Web:www.s'clov.org/ehd/unifiii.htmi <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 anew Lead User is added. <br /> Facility Information <br /> Facility IDN CERSID# DBA <br /> Phone <br /> Address <br /> Business Owner Information <br /> Name - Phone# Email Address <br /> Address <br /> Authorized Lead Users—Designate at least 2 people with different email addresses <br /> J�e Title Phone# Email Address <br /> e TitlePhone# Email Address <br /> e Title Phone# Email Address <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 Joaquin County—attach additional sheet if necessary <br /> FaClydyID# CERSID# DBA Address <br /> Facility ID# CERS ID# DBA Address <br /> Facility ID# CERS ID# DBA Address <br /> Facility ID# CERS ID# DBA Address <br /> Certification—I certify that I am the owner/operator or legal representative of each facility listed on 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 /> Signature of Owner/Operator or Legally Designated Representative Printed Name Title <br /> Name of Document Preparer Data <br />