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T N E • C t T Y • O F
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City of Coppell Public Works Dept.
816 S. Coppeli 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.
Date of Registration �ti��5'� '� ���
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Name: -Jc>�^ ✓1�5(��
Name ofCompany: J'1 �"/� /'ILf''�� v�L�rlU�-✓
Mailing Address: I b I� JV �I�"�C ��I�'/ �`�/"�'����, � 7S���J
(Street&Number/PO Box, City, tate and Zip)
Physical Address: ��M� C5 C�a;��
(Street&Number, City, State and Zip)
Office Phone Number: (�d�"�y�l� l
Mobile Phone Number: � �� �d`7�t- �d��
E-mail Address: ��✓r� � Ocek�/p�„/� � /�E�-'�'
T H E • C I T Y • O F
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City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
001339-0001 Debbie T. 08/13/2018 11: 26AM
ENERGOV INVOICE
Ansley, John (A&A Active Backflow)
2018 Item: INV-00011208
Balance due: 0. 00
Balance unpaid: 0. 00
Backflow Contractor
Registration 75 . 00
Payment Id: 7884
75. 00
Subtotal 75.00
Total 75. 00
CHECK 75 . 00
Check Number 3130
Change due 0. 00
Paid by: Ansley, John (A&A Active
Backflow)
Thank you for your payment
CUSTOMER COPY
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