Burke, LorenBackflow 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 rgovprodweb.coppelltx.gov/Ene rGov_Prod/Se l fSe rvi ce #/home
Cit y of Cop pell P ub lic W orks Dep t .
816 S. Co pp ell Rd ., S uite 103
Co pp ell, TX 75019
972-462-5150
10/4/2018
Loren Burke
Shane Burke Irrigation, Inc
City
Sachse
State / Province / Region
TX
Postal / Zip Code
75048
Country
USA
Street Address
6622 Eastview
Address Line 2
9729803734
4693440622
planning@sbirrigation.com
INV-00012191
City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
001650-0001 Debbie T. 10/04/2018 02 : 18PM
ENERGOV INVOICE
Burke, Loren (Shane Burke Irrigation, Inc)
2018 Item: INV-00012191
Balance due: 0 . 00
Balance unpaid: 0. 00
Backflow Contractor
Registration 75 . 00
Payment Id: 9314
--------------
75.00
Subtotal 75.00
Total 75. 00
CREDIT CARD - UTILITY OPS 75 . 00
Visa ************6761
Ref=2158086601
Auth=B49302
20181004FEFF
AID=A0000000031010
Invoice=78200620181004141736
AuthCode=B49302
Entry=Chip Read
AppLabel=VISA DEBIT
ATC=006D
Seq=�8200620181004141�36
--------------
Change due 0.00
Paid by: Burke, Loren
Signature:
Thank you for you� payment
CUSTOMER COPY
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