HomeMy WebLinkAboutCM Marin Energy Watch PartnershipPG&E ENERGY WATCH
Marin Energy Watch Partnership
AUTHORIZATION TO RECEIVE CUSTOMER
INFORMATION OR ACT ON A CUSTOMER'S BEHALF
SUBMITTED TO THE FOLLOWING Please check all that apply: PG&E _X__ SCE
SoCalGas SDG&E
THIS IS A LEGALLY BINDING CONTRACT READ IT CAREFULLY
(Please Print or Type)
I, _______ __,J'"'"im'"'-'-'S=--c=h-'-'u""'tz=------------------C-=-=-=ity-'--'-'M=a=n=a=gi.::e..:..r _______ _
NAME TITLE (IF APPLICABLE)]
of __ __,C"'"itya.,......ao=f--'S=-=a=n..:..R'""a=f=a=e..:..I ________________________ (Customer) have the following
NAME OF CUSTOMER OF RECORD
1400 Fifth Avenue San Rafael CA
MAILING ADDRESS CITY STATE
and do hereby appoint Dana Armanino, Marin Co. Community Development Agency
NAME OF THIRD PARTY
94901
ZIP
of __ C_o_u_n"""ty~o..:..f"""M~a"""'ri"""'n .... 1 ..:..35..:..0'-1"""C""'--'-'iv--ic_C __ e ___ n ..... te~r ..... D_r ____ • ._, S""'"a=n"'""""R""'"a"'"fa=ec..al---C __ A .......... 9 __ 4""'"90""'"3"--_______________ _
MAILING ADDRESS 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. To be submitted electronically
SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER
2 . ----------------------------SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER
3. --------------------------------SERVICE ADDRESS CITY SERVICE ACCOUNT NUMBER
(For more than three accounts, please list additional accounts on a separate sheet and attach ii 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):
X
X
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 Utility1 .
2. Request and receive copies of correspondence in connection with my account(s) concerning (initial all that apply):
X a. Verification of rate, date of rate change , and related information;
___ b. Contrasts and Seivice Agreements;
___ c. Previo us or proposed issuance of adjustmentslcredits; or
___ d. Other previously issued or unresolved/disputed billing adjustments.
3. Request im•estigation of my utility bill(s).
-"""X~-4. Request special metering, and the right to access interval usage and other metering data on my account(s).
--"-X'---_ 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, I understand I
may be responsible for charges that may be incurred to process this request.
4-3-735
PG&E ENERGY WATCH
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 BASIS 2 (initial one box only}:
2If no time period is specified, authorization will be limited to a one-time authorization
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).
One yea r a utho ri;wtion Request s fo r information and/or for the acts and fun ctions specified above will be accepted and
processed each time requested with in the twelve month pe ri od from tho date of ex ec ut ion of t his Authoriz ati on.
X Authorization is given for the period commencing with the date of execution until 07/05/2021 (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: _______ _
X Electronic format via electronic mail (if applicable) to this e-mail address: umsjohn@comcast.net or darmanino@marincounty.org
I (Customer), Jim Schutz (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.
[This form must be signed by someone who has authority to financially bind the customer (for example, CFO of a company or
City Manager of a municipality}.]
r~t J1
AUTHORlzkecrs"TOMERSIGNATlJRE ,r
(415) 485-3070
TELEPHONE NUMBER
Executed this Q £3 day of 63 2018 ~ San Rafael, CA
MONTH YEAR CITY AND STATE WHERE EXECUTED
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
Marin County Community Development Agency
COMPANY
Executed this _____ day of ________ _
MONTH YEAR
(415) 473-3292
TELEPHONE NUMBER
Authorization to Receive Customer Information or Act on a Customer's Behalf
This is a legally binding contract, please read carefully.
1,Jim Schutz, City Manager
NAME & TITLE (IF APPLICABLE)
of City of San Rafael
MCE CUSTOMER NAME (ON ACCOUNT)
1400 Fifth Avenue San Rafael
MAILING ADDRESS CITY
have the following mailing address
CA 94901
STATE ZIP
and do hereby appoint the County of Marin and all of its authorized energy contractors
NAME OF THIRD PARTY
3501 Civic Center Dr., Rm 308 San Rafael CA 94903
MAILING ADDRESS CITY STATE ZIP
to act as my agent and consultant (Agent) for the listed account(s) and in the categories
listed below:
Accounts Included in this Authorization:
SERVICE ADDRESS AND CITY SERVICE ACCOUNT NUMBER
See attached List See attached list
SERVICE ADDRESS AND CITY SERVICE ACCOUNT NUMBER
SERVICE ADDRESS AND CITY SERVICE ACCOUNT NUMBER
(For more than three accounts, please list additional accou nts 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 a cost to you, the customer.
Requests for information may be limited to the most recent 12 month period.
...... --~--.....:--,.... /';.~.,.. ~ .:., , ...
tr \-· {( hl '-1MCE Clean Energy
M y comnrnnity. My choice.
Authorization to Receive Customer Information or Act on a Customer's Behalf
The Authorization to Receive Customer Information or Act on a Customer's Behalf form
permits account holders to specifically delegate certain rights to third parties concerning
MCE account(s). The MCE customer may permit a third party to receive information or
transaction business on his or her behalf. The customer must specify what information the
third party is entitled to receive, what if any act(s) the third party may transact on his/her
behalf, and whether the authorization is being provided on a one time basis or on a longer
term basis (not to exceed three years).
Please return the completed application to MCE. Electronic copy preferred.
Mailing Address
MCE
1125 Tamalpais Avenue
San Rafael, CA 94901
Fax
(415) 459-6010
Visit mceCleanEnergy.com for more information about MCE.
Email
info@mceCleanEnergy.com
Please keep a copy of the completed authorization form for your records.
Release of Account Information:
MCE 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:
darmanino@marincounty.org
(Customer), .Jim Schutz, City Manager (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 MCE listed at the
top of this form and that I have authority to financially bind the Customer of MCE. 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 MCE reserves the right to verify any authorization request
submitted before releasing information or taking any action on my behalf. I authorize MCE
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 MCE 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 City Manager of a municipality).]
U ZED CUSTOMER SIGNATURE Jim Schutz, City Manager, City of San Rafael
(415) 485-3070
TELEPHONE NUMBER
Executed this~ day of ~~C 2018 at San Rafael , CA .
DAY MONT YEAR CITY AND ST A TE WHERE EXECUTED
I (Agent), hereby release, hold harmless, and indemnify the Marin Energy Authority 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.
I (Customer) authorize my Agent to act on my behalf to perform the following
specific acts and functions (initial all applicable boxes):
~ 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 Marin Energy Authority1.
~ Request and receive copies of correspondence in connection with my
account(s) concerning (initial all that apply):
~ Verification of rate, date of rate change, and related information;
~ Contracts and Service Agreements;
• Previous or proposed issuance of adjustments/credits; or
• Other previously issued or unresolved/disputed billing adjustments.
~ Request investigation of my utility bill(s).
~ Request special metering, and the right to access interval usage and other
metering data on my account(s).
~ Request rate analysis.
• Request rate changes.
• Request and receive verification of balances on my account(s) and
discontinuance notices.
1 MCE 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.
I (Customer) authorize the release of my account information and authorize my
agent to act on my behalf on the following basis 2 (initial one box only):
2 If no time period is specified, authorization will be limited to a one-time authorization
• 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).
• 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.
~ Authorization is given for the period commencing with the date of execution
until 011os12021 (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.
AGENT CUSTOMER SIGNATURE
415-4 73-3292
TELEPHONE NUMBER
County of Marin
COMPANY
Executed this_ day of____ at ____________ _
DAY MONTH YEAR CITY AND ST A TE WHERE EXECUTED
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: County of Marin
Contractor's Contact: Dana Armanino
Contact's Email: darmanino@countyofmarin.org
D FPPC: Check if Contractor/Consultant must file Form 700
Step RESPONSIBLE DESCRIPTION
DEPARTMENT
1 Project Manager a. Email PINS Introductory Notice to Contractor
b. Email contract (in Word) & attachments to City
Atty c/o Laraine.Gittens@cityofsanrafael.org
2 City Attorney a. Review, revise, and comment on draft agreement
and return to Project Manager
b. Confirm insurance requirements, create Job on
PINS, send PINS insurance notice to contractor
3 Project Manager Forward three (3) originals of final agreement to
contractor for their signature
4 Project Manager When necessary, * contractor-signed agreement
agendized for Council approval
*PSA > $20,000; or Purchase> $35,000; or
Public Works Contract> $125,000
Date of Council approval
PRINT CONTINUE ROUTING PROCESS WITH HARD COPY
s Project Manager Forward signed original agreements to City
Attorney with printed copy of this routing form
6 City Attorney Review and approve hard copy of signed
agreement
7 City Attorney Review and approve insurance in PINS, and bonds
(for Public Works Contracts)
8 City Manager/ Mayor Agreement executed by Council authorized official
9 City Clerk Attest signatures, retains original agreement and
forwards copies to Project Manager
COMPLETED
DATE
NA
7/31/2018
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4-3-735