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1 ISCELLANEOUS BILLING REQUEST FORA <br /> ORIGINATOR'S NAME /EW# Lowen /2294 EXT 7443 DATE 7/19/2012 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES El <br /> ACCOUNT SETUP <br /> CUSTOMER INFORMATION <br /> CUSTOMER NAME City of Eugene <br /> PRESMISES /PROPERTY ADDRESS <br /> MAILING ADDRESS <br /> CONTACT NAME <br /> BUSINESS PHONE# / CELL # <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 /> ADJUSTMENTS AND CHARGES <br /> RATE TO BE USED Decrease SLH1 AMOUNT TO BILL 5.15 x 2 = 10.30 <br /> RATE TO BE USED Increase SLH& AMOUNT TO BILL 4.15 x 2 = 8.30 <br /> RATE TO BE USED AMOUNT TO BILL <br /> ACCOUNT NUMBER 23736 -142 BUNCH CODE TO BE USED <br /> NOTES (REASON FOR ADJUSTMENT, ETC.) <br /> Per Jim Riggs at COE replaced (2) 100 W HPS S/L @ COE Pole 26651 @ 1604 Fircrest and COE pole 28192 @ 2125 <br /> Ironwood w/ (2) 70W HPS. Change to be effective 6/20/2012 <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 7 -18 -12 DATE ENTERED EW20367 -18 -12 <br /> ENTERED BY EW2036 CYCLE NUMBER <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 103316024 <br />