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Willaims, James City of Coppell, TX Public Works 255 Parkway Blvd, Coppell, TX 75019 Coppell, TX 75019 972-304-3500 Welcome 001904-0001 Debbie T. 11/14/2018 09: 42AM ENERGOV INVOICE Williams, James (Westerr_ States Fire Protection; 2018 Item: INV-18-00012918 Balance due: 0. 00 Balance unpaid: 0 . 00 Backflow Contractor Registration 75 . 00 Payment Id: 10370 -------------- 75. 00 Subtotal 75. 00 Total 75. 00 CREDIT CARD - UTILITY OPS 75 . 00 MaSterCard ************7136 Ref=2402291801 Auth=144326 201811143202 AID=A0000000041010 Invoice=78200620181114094237 AuthCode=144326 Entry=Chip Read AppLabel=DEBIT MASTERCARD ATC=002C Seq=78200620181114094237 -------------- Change due 0.00 Paid by: Williams, James Signature: Thank you for your payment CUSTOMER COPY T H E • C [ T Y • O F �� PPELL `N=..:,,�•�, `.�,• �r ,�V,,.�:,: ,s � `��-..�F 1. ._ �K''�_�1G, �y;;..-a. � r. z'r{.^y�.�s_'„ t J �.'�, wr-'3�ti.�,.�'a O .�"V: '•�'. fi � � � D 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: ��iit.�� �.(�� ( � �G� v� 7 � �( O^ c Name ofCompany: ���`^ fi��eS � '"� ���''��i��'—' t� -�- / � � � MailingAddress: Z�"I � �• (�G '� � �r I�', � �r�c,H(/� J�v�.,� V. t � K ��'p f"2_ (Street&Number/PO Box, City, State and Zip) Physical Address: ��'Z� (Street&Number, City, State and Zip) Office Phone Number: � � � l.P � ( � �� il �Z Mobile Phone Number: 2 ( ( � ` 3 � 5 S` � E-mail Address: S G b'�t �5 � w'� '` � �"" S `-' l�iJ S � r ' lJ S ��..,.,x.v�K,,�ga,.,,�.:�.�. . .. . . .,., _ :-. . :, ..,,.•.�.,,„� ��.2 y.�