Authorization - SCE - 2013-02-14 SOUTHERN CALIFORNIA
AUTHORIZATION TO: RECEIVE CUSTOMER
- E D I S O N INFORMATION OR ACT ON A CUSTOMER'S BEHALF
An EDISON INTERNATIONAL Company
THIS IS A LEGALLY BINDING CONTRACT—READ IT CAREFULLY
SCOTT CARROLL GENERAL MANAGER
NAME
TITLE(IF APPLICABLE)
of COSTA MESA SANITARY DISTRICT (Customer)have the following mailing address
NAME OF CUSTOMER RECORD
628 W. 19TH STREET COSTA MESA CA 92627
MAILING ADDRESS CITY STATE ZIP and do hereby appoint
Utility Cost Management LLC of 6475 N.Palm Avenue,Suite 105
NAME OF THIRD PARTY MAILING ADDRESS
Fresno CA 93704
CITY STATE ZIP
to act as my agent and consultant(Agent)for the listed account(s)and in the categories Indicated below:
ACCOUNTS INCLUDED IN THIS AUTHORIZATION
1 SEE ATTACHED LIST OF ACCOUNTS 30
SERVICE ADDRESS SERVICE ACCOUNT NUMBER
2. 30
SERVICE ADDRESS SERVICE ACCOUNT NUMBER
3. 30
SERVICE ADDRESS SERVICE ACCOUNT NUMBER
(For more than three accounts,please list additional accounts on a separate sheet and attach It to this form)
INFORMATION, ACTS AND FUNCTIONS AUTHORIZED —This authorization provides authority to the Agent.
The Agent must thereafter provide specific written instructions/requests (e-mail is acceptable) about the
particular account(s) before any information is released or action is taken. In certain instances, the
requested act or function may result in cost to you,the customer. Requests for Information may be limited to
the most recent 12 month period.
I (Customer) authorize my Agent to act on my behalf to perform the following specific acts and functions
(initial all applicable boxes):
Initla` 1. Request and receive billing records, billing history and all meter usage data used for bill calculation for all of my
account(s),as specified herein,regarding utility services furnished by the Utility.'
❑ 2. EPA Benchmarking
.-Initial: 3. Request and receive copies of correspondence in connection with my account(s)concerning(Initial all that apply):
Inih a. Verification of rate,date of rate change,and related information;
b. Contracts and Service Agreements; •
Ini - Previous or proposed Issuance of adjustments/credits;or
India d. Other previously issued or unresolved/disputed billing adjustments.
..lraitta 4. Request investigation of my utility bill(s)
❑ 5. Request special metering,and the right to access interval usage and other metering data on my account(s).
❑ 6. Request rate analysis.
initi: ` 7. Request rate changes.
8. Request and receive verification of balances on my account(s)and discontinuance notices.
The Utility will provide standard customer information without charge up to two times in a 12 month period per service account.After
two requests In a year,I understand I may be responsible for charges that may be incurred to process this request.
Form 14-796 Page 1 of 2 4/2011
AUTHORIZATION TO: RECEIVE CUSTOMER INFORMATION OR ACT ON A CUSTOMER'S BEHALF
I(CUSTOMER)AUTHORIZE THE RELEASE OF MY ACCOUNT INFORMATION AND AUTHORIZE MY AGENT
TO ACT ON MY BEHALF ON THE FOLLOWING BASIS2 (Initial one box only):
n One time authorization only (limited to a one-time request for information and/or the acts and functions
Secified above at the time of receipt of this Authorization).
n One year authorization - Requests for information and/or for the acts and functions specified above will be
accepted and processed each time requested within the twelve month period from the date of execution of
this Authorization.
Inhorization is given for the period commencing with the date of execution until
3/31/2013 (Limited in duration to three years from the date of execution.) Requests for
information and/or for the acts and functions specified above will be accepted and processed each time
requested within the authorization period specified herein
RELEASE OF ACCOUNT INFORMATION:
The Utility will provide the information requested above,to the extent available,via any one of the following.
My(Agent)preferred format is(check all that apply):
Hard copy via US Mail(if applicable):.
Facsimile at this telephone number: br @utilitycostmanagement.com
f Electronic format via electronic mail (if applicable)to this e-mail address
I (Customer), SCOTT CARROLL (print name of authorized signatory), declare
under penalty of perjury under the laws of the State of California that I am authorized to execute this document
on behalf of the Customer of Record listed at the top of this form and that I have authority to financially bind the
Customer of Record. 1 further certify that my Agent has authority to act on my behalf and request the release of
information for the accounts listed on this form and perform the specific acts and functions listed above. I
understand the Utility reserves the right to verify any authorization request submitted before releasing
information or taking any action on my behalf. I authorize the Utility to release the requested information on my
account or facilities to the above Agent who is acting on my behalf regarding the matters listed above. I hereby
release, hold harmless, and indemnify the Utility from any liability, claims, demands, causes of action,damages,
or expenses resulting from: 1) any release of information to my Agent pursuant to this Authorization; 2) the
unauthorized use of this information by my Agent; and 3) from any actions taken by my Agent pursuant to this
Authorization, including rate changes. I understand that I may cancel this authorization at any time by submitting
a written request. [This form must be signed by someone who has authority to financially bind the customer
(for example,CFO of a company or C' .r'.ger of a municipality).]
X i (L1'? C-43 4°°
— -AUTHORIZED CUSTOMER:SIGNATURE`•° TELEPHONE NUMBER~
Executed this l day of r 1,0(� at l C A
MONTH; YEAR' CITY AND STATE RE EXECUTED;
I (Agent), hereby release, hold harmless, and indemnify the Utility from any liability, claims, demand, causes of
action�„da ages, r expen es7 suiting from the use of customer information obtained pursuant to this authorization
and f t e takir of. ny act' n ursuant to this authorization,including rate changes.
(559)261-9230
AGENT SIGN U E TELEPHONE NUMBER
Utility Cost Management LLC
COMPANY
Executed this 14TH day of FEB 2013
MONTH YEAR
2 If no time period Is specified,authorization will be limited to a one-time authorization.
Form 14-796 Page 2 of 2 4/2011