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Application Date: Application No: CUSTOMER INFORMATION: Applicant/Contact Name: (name as it appears on your bill) Region (check one): Address of Contact Person: City: State: Zip: Daytime Phone: Alternate Phone: PROJECT DETAILS: Describe the proposed boundaries of the rear property undergrounding project: Underground trench occupants (Applicant is required to request, coordinate and assume all costs for agencies other than the City of Anaheim Public Utilities Department): Provider: Provider: Provider: ANAHEIM PUBLIC UTILITIES Rear Property Undergrounding Program Application Electric Telephone Cable TV Other West City Limits to Euclid St. Central - between Euclid St. and State College Blvd. East City Limits to State College Blvd. rev. 3.9.07 page 1 of 2 ---PAGE BREAK--- Affected Properties (list the properties affected by the proposed undergrounding): Address Name of Property Owner 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Fill out and sign this application form. Keep a copy for your files, and deliver or mail original to: Anaheim Public Utilities Electrical Engineering, Suite 701 201 S. Anaheim Blvd. Anaheim, CA 92805 Attn: Rear Property Undergrounding Program AGREEMENT CLAUSE: I have read the associated program information, and understand that the City of Anaheim will assist with the design of the project, and is not responsible for the costs associated with construction and materials for rear property undergrounding. Customer Signature: Date: Printed Name: rev. 3.9.07 page 2 of 2