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SOUTHERN CALIFORNIA EDISON STREETLIGHT AUTHORIZATION <br />DEVELOPERIAPPLICANT MUST PROVIDE THIS FORM <br />COMPLETED BY THE PUBLICAUTHORITY <br />FOR ANY SCE -OWNED STREETLIGHT INSTALLATION, REMOVAL OR CHANGE REQUESTS <br />Incomplete forms will be returned and not processed <br />rihr of Santa Ann <br />PUBLIC AUTHORITY NAME: <br />SuilderlDeveloper Name: Phone #: <br />TracttRef # Streetlight Location See Attached SCE Maps <br />Please Check one: ❑ Installation ❑ Removal X Change to LED <br />Number of Lamp(s) Lamp Size Lamp Type <br />—21- —10_ _HPS _ <br />-1 — —20— -HPS - <br />New Insta/latlons <br />Public Authority Responsibility for Streetlight Monthly Billing <br />Please Check one and till out applicable dates: <br />_Upon Energizing <br />❑If Public Authority Is collecting Builder/Developer Advanced Energy Payment, <br />Indicate date collected. ( ) <br />Monthly Billing: _Establish new Service Account (SA) Use existing SA# <br />_ Commitment Date - <br />Date Agreed upon by SCE and Public Authority (_) or no later than 36 months from first <br />streeUlght energized whichever Is earlier. <br />Monthly Billing: _Establish new Service Account (SA) Use existing SA # <br />_Public Authority Is not responsible <br />HOAArea Name Other Entity (please defina) <br />Public Authority Notes: <br />Authorized Public Authority Agent <br />Tyrone Chesanel< 8/30/18 <br />Print name Date <br />Phone # 714.647.5045 <br />Principell CE <br />Title <br />TO BE COMPLETED BYSCE <br />ACTION: ENTER TRACTIREF# ON DM PROGRAM NAME FIELD. <br />District_ Planning AOR <br />OM SR # Product # (one per SLA) <br />PLANNER NAME (PRINT) <br />FORWARD COMPLETED COPIES OF THE SLA FORM. MAP AND CS0272 CONTRACT, IF APPUCA13LE TO: <br />"Street & Outdoor Lightrga =�on" Santa Ana Bldg. D <br />� <br />SCE SOL04M Rev 04.20.15 H <br />112xullQilT 01 <br />