Travis, JohnBackflow 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
10/3/2018
John Travis
Lakeside Irrigation
City
Heath
State / Province / Region
TX
Postal / Zip Code
75032
Country
USA
Street Address
504 Willow Springs
Address Line 2
9727228020
2149269944
ryanmlakesideirrigation@hotmail.com
INV-00012172
City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
001640-0001 Debbie T. 10/03/2018 10 : 43AM
ENERGOV INVOICE
Travis, John (Lakeside Irrigation)
2018 Item: INV-00012172
Balance due: 0. 00
Balance unpaid: 0 . 00
Backflow Contractor
Registration 75 . 00
Payment Id: 9272
--------------
75.00
Subtotal 75.00
Total 75.00
CREDIT CARD - UTILITY OPS 75 . 00
MasterCard ************5231
Ref=2149339801
Auth=81496J
20181003181B
AID=A0000000041010
Invoice=78200620181003104319
AuthCode=81496J
Entry=Chip Read
AppLabel=MasterCard
ATC=0060
Seq=78200620181003104319
Change due 0. 00
Paid by: Travis, John (Lakeside
Irrigation)
Signature:
Thank you for your payment
CUSTOMER COPY