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• <br /> • • <br /> MISCELLANEOUS BILLING REQUEST FORM <br /> ORIGINATOR'S NAME /EW# Debbie Jenkins /EW2442 EXT 7117 DATE 05/23/13 <br /> NEW ACCOUNT SETUP ® ADJUSTMENTS & CHARGES ❑ <br /> ACCOUNT SETUP <br /> CUSTOMER INFORMATION <br /> CUSTOMER NAME City of Eugene <br /> PRESMISES /PROPERTY ADDRESS Knickerbocker Bridge Path Lighting <br /> MAILING ADDRESS <br /> CONTACT NAME Kris Olson <br /> BUSINESS PHONE# / CELL # (541) 682 -4961 <br /> FAX NUMBER <br /> SSN OR TIN /EIN# <br /> REFERENCE INFORMATION <br /> FULL LEGAL NAME, RELATIONSHIP <br /> COMPLETE ADDRESS <br /> PHONE(HOME, BUSINESS,CELL) <br /> BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) <br /> OWNERS LEGAL NAME & SSN <br /> ACCOUNTS PAYABLE <br /> PARTNERS (FULL LEGAL NAMES & SSN <br /> CORPORATION OFFICERS <br /> TITLE, FULL LEGAL NAME(S) <br /> ADDRESS <br /> PHONE (HOME, BUSINESS, CELL) <br /> BANK INFORMATION <br /> BANK NAME <br /> BRANCH (IE. MAIN BRANCH, EUGENE OR) <br /> AUTHORIZED PARTIES <br /> NOTES( CONTRACT #, JOB #, JOB SPECIFICS, ORDERED BY, ETC.) <br /> EWEB JOB #36942, EWEB DWG #B- 26909, WT #85712 <br /> ADJUSTMENTS AND CHARGES <br /> RATE TO BE USED SLH7 AMOUNT TO BILL 4X $4.48 = $17.92/MO. <br /> RATE TO BE USED AMOUNT TO BILL <br /> RATE TO BE USED AMOUNT TO BILL <br /> ACCOUNT NUMBER 23736 - 142 /EWEB V13405 BUNCH CODE TO BE USED <br /> NOTES (REASON FOR ADJUSTMENT, ETC.) <br /> 4 NEW 70 -WATT LIGHTS FOR BIKE PATH BEGINNING @ KNICKERBOCKER BRIDGE TO 1 -5 UNDERPASS SOUTH SIDE. <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 12/10/13 DATE ENTERED 12/10/13 <br /> ENTERED BY EW2401 CYCLE NUMBER 011 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 100423970 <br />