Kvaal, Travis T H E • C 1 T Y � O F
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BACKFLOW REGISTRATION FORM
Registration is for one year from the date of registration or r�registration.
Date of Registration: `t� ,^L� � � �
Name: �1S t�ur��..-1
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Company: Lc�e��C, C��t� /�"C��n���l�. �l���c�i 'r lv c.�
Mailing Address: ��Z°� V--cx�t��>c^c'�:c� `..�_ (����1� �f� �x �����
(Street&N� ber/PO Box,City,State and Zip)
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Physical Address: �Co .���a�;•� �
(Stree� Number,City,State and Zip)
Office Phone Number: ��Z` ��� '" �;`����l
Mobile Phone Number: ��Z � k��i� ' ��� �'�
E-mail Address: /.��« � �l �� _-EY✓���� �
City of Coppell Public Works Dept.
816 S. Coppell Road
Coppell, TX 75019
972-462-5150
www.coppelltx.gov
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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
001426-0001 Debbie T. 08/28/2018 10:24AM
ENERGOV INVOICE
KVAAL, TRAVIS (ACCURATE AND ACCOUNTABLE BACKFLOW)
2018 Item: INV-00011485
Balance due: 0. 00
Balance unpaid: 0 . 00
Backflow Contractor
Registration 75 . 00
Payment Id: 8291
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75.00
Subtotal 75. 00
Total 75. 00
CREDIT CARD - [JTILITY OPS 75 . 00
Visd ************4502
Ref=1946732101
Auth=072411
2018082851C2
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Change due 0. 00
Paid by: KVAAL, TRAVIS
Signature:
Thank you for your payment
City of Coppell, TX COPY