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Macuso, Ross City of Coppell, TX Public Works 255 Parkway Blvd, Coppell, TX 75019 Coppell, TX 75019 972-304-3500 Welcome 001823-0003 Debbie T. ll/02/2018 02: OlPM ENERGOV INVOICE Mancuso, Ross 2018 Item: INV-00012691 Balance due: 0. 00 Balance unpaid: 0 . 00 Backflow Contractor Registration 75. 00 Payment Id: 10038 -------------- 75. 00 Subtotal 75. 00 Total 75.00 CREDIT CARD - UTILITY OPS 75 . 00 Visa ************2366 Ref=2332776301 Auth=061476 20181102BEF7 AID=A0000000031010 Invoice=78200620181102140102 AuthCode=061476 Entry=Chip Read AppLabel=VISA DEBIT ATC=008D Seq=78200620181102140102 -------------- Change due 0. 00 Paid by: Mancuso, Ross Signature: Thank you for your payment CUSTOMER COPY � _ . n�.=�i T H E • C [ T Y • O F �� PPELL �`y:•� A t�Sr, i,7.�" �r �T�.:,.r-!:,� '- � ` .4 1K.' � }G �,:1ia �"`� %� Zst �;;'{`�y'rC. -t. �,4,;' a. •��• � h,�s'�r'O �'--�'' ��`''J' ��".:� a fi '�-" `= �� � h � , \ 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 ��� -� ' � S � Name: I`��'�`� /G lf�ic. c"�� `.. Name of Company: Mailing Address: ���J' L_c �t�.i i��y ��N� (Street&Number/PO Box, City, State and Zip) Physical Address: (Street&Number, City, State and Zip) Office Phone Number: Mobile Phone Number: ,1�'i� - ���� � �'S� ( 1 E-mail Address: 1 c;`; ; 1/)i'�� ��`�c �. C ����a�` ; [��� �