Roppolo, Brett T H E • C I T Y • O _F
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Ciry of Coppell Public Works Dept.
816 S. Coppeli Road
Coppell, TX 750�9
972-462-5150
www.coppelltx.gov
BACKFLOW REGISTRATIDN FORM
Registration is for one year from the date of registration or re-registration.
Date of Reglstration Q��d� r �r 2��
Name: I��� ri���l�
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Ma111ngAddress: �0��� d1`�Yv���C� D� pq�tas TzC -7�a�
(Sfreet&Number/PO 8ox,City,State and Zrp)
Physical Address: �0��� d�`��Pt�- �� Da lia 5 T�l. �f��.l�1
{Street&Number, Ciry,Stafe and Zip)
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E-mail Address: � rOY Fb1D[� ���+'' Fl r�.GOwi
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BILLING CONTACT
Brett Roppolo �
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INVOICE NUMBER INVOICE DATE INVOICE DUE DATE INVOICE STATUS INVOICE DESCRIPTION
INV-00012115 10/01/2018 10/01/2018 Paid In Full NONE
REFERENCE NUMBER FEE NAME TOTAL
Misc Fee Backflow Contractor Registration $75.00
SUB TOTAL $75.00
REMITTANCE INFORMATION TOTAL $75.00
City Of Coppell
P.O. Box 9478
Coppell,TX 75019
October 01,2018 255 Parkway Boulevard, Coppell Texas 75019 Page 1 of 1