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• 1ISCELLANEOUS BILLING REQUEST FORA <br /> ORIGINATOR'S NAME /EW# Lowen /22194 EXT <br /> 7443 DATE 8/21/12 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES EZ <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 - 5.15X2 = -10.30 <br /> RATE TO BE USED Increase SLH7 AMOUNT TO BILL 4.15X2 = $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 @ COE replaced (2) 100 W HPS S/L @ COE Pole 97029 @ 1698 Ironhorse and COE pole 99849 @ 3588 <br /> Spring Blvd. w/ (2) 70W HPS. Change effective 7/19/2012. <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 8 -21 -12 DATE ENTERED 8 -21 -12 <br /> ENTERED BY ew2036 CYCLE NUMBER 01 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 103316024 <br />