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City of Coppell Public Works Dept.
816 S. Coppell Road
Coppell, TX 75019
972-462-5150
www.coppelltx.gov
BACKFLOW REGISTRATION FORM
Registration is for one year from the date of registration or re-registration.
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Date of Registration � � ' � � C �
Name:
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Name of Company: \ �IJ V" Jr�C� �'- ( L ��
Mailing Address: � � `� `"' �'�� `'�J°� "-�'���� � ��
(Street&Number/PO Box, City, State and Zip)
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Physical Address:
(Street&Number, City, Sfate and Z p)
Office Phone Number: � � � �� � � � � � ^�
Mobile Phone Number: � J � ! � � '�
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Backflow Tester Registration
Date *
Te ste r Name *
Name of Company *
Addre ss *
Office Phone
Numbe r *
M obile Phone
Numbe r
Email Addre ss *
Inv oice Numbe r *
Registration is good for one year from the date of registration.
Once your information has been entered into our system, you will receive an email with your Invoice number. You will
need this Invoice number to pay for your registration on line at:
https://e ne rgovprodw e b.coppe l l tx .gov/Ene rGov_P rod/Se l fSe rvice #/home
Cit y o f Co p p ell P u blic W o r k s Dep t .
816 S . Co p p ell Rd ., S u ite 103
Cop p ell, TX 75019
972-462-5150
10/2/2018
Santay Chandrahas
Prime Inspection
City
Garland
State / Province / Region
TX
Postal / Zip Code
75042
Country
USA
Street Address
3310 West Walnut St
Address Line 2
2147385657
2147385657
primeinspection@gmail.com
INV-00012146