Renteria, Jim City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
001823-0002 Debbie T. 11/02/2018 08 : 36AM
ENERGOV INVOICE
Renteria, Jim (Western States Fire Protection)
2018 Item: INV-00012664
Balance due: 0. 00
Balance unpaid: 0. 00
Backflow Contractor
Registration 75 . 00
Payment Id: 10019
75. 00
Subtotal 75.00
Total 75.00
CREDIT CARD - UTILITY OPS 75. 00
MaSterCard ************5287
Ref=2329107501
Auth=06271Z
20181102A5A5
AID=A0000000041010
Invoice=78200620181102083540
AuthCode=06271Z
Entry=Chip Read
AppLabel=MASTERCARD
ATC=0001
Seq=78200620181102083540
--------------
Change due 0. 00
Paid by: Renteria, Jim
Signature:
Thank you for your payment
CUSTOMER COPY
T H E • C I 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 Registration � � � � � ��
Name: �� `...-� I'�t:� ��i".`c1
Name ofCompany: �i�FC�,-t J��>, ��:`� '7`, fr�F.'��--�
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Mailing Address: 23 }S '1�
(Street&Number/PO Box, City, State and Zip)
Physical Address: 5�'�"�
(Street&Number, City, State and Zip)
Office Phone Number: 'Z�h � �' 3 �� - �5 (,' Z
Mobile Phone Number: 2-�� "�Z �' - � �� -7
E-mail Address: 1 �✓�-� , f f+'� �t�^��c� �� �/$F jJ : Lr S
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