Rose, Douglas City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
001852-0001 Debbie T. 11/�6/2018 11 : 50AM
ENERGOV INVOICE
Rose, Douglas (Approved Backflow Testing)
2018 Item: INV-00012761
Balance due: 0. 00
Balance unpaid: 0. 00
Backflow Contractor
Registration 75 . 00
Payment Id: 10139
75. 00
Subtotal 75. 00
Total 75. 00
CHECK 75 . 00
Check Number 3789
--------------
Change due 0. 00
Paid by: Rose, Douglas
Thank you for your payment
CUSTOMER COPY
DUPLICATE RECEIPT
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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 �! ` �1lg
Name:
Name of Company: �� //I
Mailing Address: � /� N "K �/I(e �� ��/��
(Street&Number/PO Box, City, State and Zip)
Physical Address: �,,'"''�
(Street&Number, City, State and Zip)
Office Phone Number:
Mobile Phone Number: ��T "t ! 7' �
E-mail Address: OIreG� � � � �► C07��