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? N E • C ! T Y • O F
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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.
Date of Regis tion � � `P � \ �
Name: 41.� �`�
Name of Company: �"' ' ` �t� � �..—
Mailing Address: � !`��� ��' `''� �' ��� �
(Street&Nu er O Box, Ci y, State and Zip)
Physical Address: �� � G.� �/�. � �'� � � ��v� �
(Street&Num er, City, Sfate and Zip)
Office Phone Number:
Mobile Phone Number: �- ��' �� 7 l i �
E-mail Address: ( _C.�✓1�, ��� •����t.f i � �p / `� I � � �
City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
001473-0001 Debbie T. 09/06/2018 11 : 04AM
ENERGOV INVOICE
Cantu, Daniel (Cantu Sprinkler, LLC)
2018 Item: INV-00011664
Balance due: 0. 00
Balance unpaid: 0. 00
Backflow Contractor
Registration 75 . 00
Payment Id: 8563
75.00
Subtotal 75. 00
Total 75. 00
CHECK 75 . 00
Check Number 1993
--------------
Change due 0. 00
Paid by: Cantu, Daniel (Cantu Sprinkler,
LLC)
Thank you for your payment
CUSTOMER COPY