HomeMy WebLinkAboutCM Customer Infromation Authorization (missing Agent signature)Pacific Gas and AUTHORIZATION TO RECEIVE CUSTOMER
Electric Company INFORMATION OR ACT UPON A CUSTOMER'S BEHALF
THIS IS A LEGALLY BINDING CONTRACT, PLEASE READ CAREFULLY
(Please Print or Type)
ILi
of City of San Rafael (Customer) have the following mailing address
NAME OF CUSTOMER OF RECORD
1400 5th Avenue
San Rafael CA 94901 , and do hereby appoint
MAILING ADDRESS CITY STATE ZIP
American Energy Partners of 2 Harris Ct Ste B-1
NAME OF THIRD PARTY MAILING ADDRESS
Monterey CA 93940
CITY STATE Z.P
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. 50 Canal Street, San Rafael 2003975593-7
SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER
2. 40 Canal Street, San Rafael 3983370550
SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER
3. 111 Morphew Street, San Rafael 9087543148
SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER
(For mon: 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):
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. Request and receive copies of correspondence in connection with my account(s) concerning (initial all that apply):
a. Verification of rate, date of rate change, and related information;
0 b. Contracts and Service Agreements;
0 c. Previous or proposed issuance of adjustments/credits; or
0 d. Other previously issued or unresolved/disputed billing adjustments.
3. Request investigation of my utility bill(s).
4. Request special metering, and the right to access interval usage and other metering data on my account(s).
0 5. Request rate analysis.
6. Request rate changes.
7. Request and receive verification of balances on my account(s) and discontinuance notices
1 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./ understand I
may be responsible for charges that may be incurred to process this request.
wtomated Document, Preliminary Statement A
Page 1 of 2
Form 79-1095
Advice 4002 -G/5349 -E
August 2018
1."
Pacific Gas and
Electric Company
AUTHORIZATION TO RECEIVE CUSTOMER
INFORMATION OR ACT UPON 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 BASISZ ktg one box only):
2 If no time period is specified, authorization will be limited to a one-time authorization
0 One time authorization only (limited to a one-time request for information and/or the acts and functions specified above at the time of
receipt of this Authorization).
0 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.
0 Authorization is given for the period commencing with the date of execution until (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:
❑ Electronic format via electronic mail (if applicable) to this e-mail address: rlegaspi@amenergypartnerS.Cog
I (Customer), (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. I 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. I understand that this agreement at all times shall be subject to such modifications as the California Public Utilities Commission may direct from
time to time in the exercise of its jurisdiction. [This form must be signed by someone who has authority to financially bind the customer (for
AUTHORY-E- 'CUSTOMER SIGNATURE
Executed this day of 3 21
MONTH YEAR
-36
/TELEPHONE NUMBER
at Q/t to
CITY AND STATE WHERE E ELUTED
I (Agent), hereby release, hold harmless, and indemnify the Utility from any liability, claims, demand, causes of action, damages, or expenses
resulting from the use of customer information obtained pursuant to this authorization and from the taking of any action pursuant to this
authorization, including rate changes.
AGENT SIGNATURE
COMPANY
Executed this day of
MONTH YEAR
Automated Document, Preliminary Statement A
TELEPHONE NUMBER
Page 2 of 2
Form 79-1095
Advice 4002 -G/5349 -E
August 2018
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CONTRACT ROUTING FORM
INSTRUCTIONS: Use this cover sheet to circulate all contracts for review and approval in the order shown below.
TO BE COMPLETED BY INITIATING DEPARTMENT PROJECT MANAGER:
Contracting Department: City Manager
Project Manager: Cory Bytof Extension: 3407
Contractor Name: American Energy Partners
Contractor's Contact: Chris Chase Contact's Email: cchase@amenergypartners.com
❑ FPPC: Check if Contractor/Consultant must file Form 700
Step
RESPONSIBLE
DESCRIPTION
COMPLETED
REVIEWER
DEPARTMENT
DATE
Check/Initial
1
Project Manager
a. Email PINS Introductory Notice to Contractor
Click here to
❑
enter a date.
b. Email contract (in Word) and attachments to City
3/24/2021
CB
Attorney c/o Laraine.Gittens@cityofsanrafael.org
2
City Attorney
a. Review, revise, and comment on draft agreement
Click here to
and return to Project Manager
enter a date.
❑
b. Confirm insurance requirements, create Job on
Click here to
PINS, send PINS insurance notice to contractor
enter a date.
❑
3
Department Director
Approval of final agreement form to send to
Click or tap
❑
contractor
to enter a
date.
4
Project Manager
Forward three (3) originals of final agreement to
Click here to
❑
contractor for their signature
When necessary, contractor -signed agreement
enter a date.
❑ N/A
5
Project Manager
agendized for City Council approval *
*City Council approval required for Professional Services
❑
Agreements and purchases of goods and services that exceed
Or
$75,000; and for Public Works Contracts that exceed $175,000
Click here to
Date of City Council approval
enter a datE
PRINT
CONTINUE ROUTING PROCESS WITH HARD COPY
6
Project Manager
Forward signed original agreements to City
Attorney with printed copy of this routing form
7
City Attorney
Review and approve hard copy of signed
3/25/21
LG
agreement
8
City Attorney
Review and approve insurance in PINS, and bonds
3/25/21
LG (N/A)
(for Public Works Contracts)
9
City Manager/ Mayor
Agreement executed by City Council authorized
City Clerk
official
10
Attest signatures, retains original agreement and
J
forwards copies to Project Manager