The URL can be used to link to this page

2018 _.,._ ..._.._.�,_____......--. _...__-- T N E � C ( T Y • O F __._._...--,__.__�._�----..___ __....._..__ _ ._ ��PP�LL ,�'`' '° ''= r�z� -� � �: ' =`:�, + •- `` • s t ";f �.`''�i, y ;.;,,, `O �' � `��..%�`'+ ��' 8 n 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 l� 3 r I l � � Name: �� Name of Company: � ��l J- N Q ��'1 C�q n� Jc�`1�� C�l� r)�C � / -�— /n Mailing Address: �3�3 �4"Gt►°1� I f Y �t � P��` ( � ��` � (Street�&Number/PO Box, City, State and Zip) Physical Address: (Street&Number, City, State and Zip) L��L � ��-i'c-�. Office Phone Number: �� I 'S� � � � q � �1 4 `• y g (�--�jt�I `� � Mobile Phone Number: �� ^ �' � � � E-mail Address: �� 1 C�� l � �� r� City of Coppell, TX Public Works 255 Parkway Blvd, Coppell, TX 75019 Coppell, TX 75019 972-304-3500 Welcome 001823-0001 Debbie T. 11/02/2018 08 : 22AM ENERGOV INVOICE Bailey, David (CISD) 2018 Item: INV-00012662 Balance due: 0. 00 Balance unpaid: 0. 00 Backflow Contractor Registration 75 . 00 Payment Id: 10016 -------------- 75. 00 Subtotal 75. 00 Total 75. 00 CHECK 75 . 00 Check Number 257994 -------------- Change due 0. 00 Paid by: Bailey, David (CISD) Thank you for your payment CUSTOMER COPY T H E • C I T Y • O F COPPELL �' ` ' �' ��' ,� �-,-. r '°""�^�—�:, ' o F`~�'` -✓,�`: �.>> 9 x A''s , a October 15, 2018 Coppell ISD Coppell, TX 75019 RE: Backflow Registration for David Bailey To Whom it May Concern: Mr. Baily's current backflow registration is due for renewal and we need the following to keep him current: 1. Copy of Driver's License 2. Copy of Backflow License 3. Current Liability Insurance (Declaration page only) 4. Calibration Report for testing device 5. $75.00 fee Should you have any questions, please give me a call. Sincerely, � ��G Debi Taber City of Coppell Public Works Dept. 816 S Coppell Rd. Coppell, TX 75019 972-462-5150 - JL... ll � � �� r•��„ .°�.� � �� ' 'x � �x�'"�� Calibration Date: 10/4/2018 MacArthur Gauge Inc. � 1523 Baccarac Court Euless, TX 76040 I Expires On: 10/4/2019 Instrument Calibration Report Registration Information: Coppell ISD 1303 Wrangler Circle Coppell, Tx 75019 Manufacturer: Conbraco Serial Number: 258000 Model: 40-200-TK Calibration Tag: 1228 Type: Differential Other: N/A Gauge Tested Within Tolerances: Passed _ ___ ____ __ __ _ _ _ Reference Pressure/Reading: 0 psi = N/A 5 psi = 5 10 psi = N/A 15 psi = N/A 1 psi = 1 6 psi = N/A 11 psi = N/A 2 psi = 2 7 psi = 7 12 psi = N/A 3 psi = N/A 8 psi = N/A 13 psi = N/A 4 psi = N/A 9 psi = N/A 14 psi = N/A _ _ _ __.._ _ __ __ _ _ _ _ : This gauge is calibrated to an accuracy of+/-.2 PSID All test instruments used in the calibration of this gauge conform to ASME B40.1 and are traceable to N.I.S.T. Service/Calibration Notes Entry Type: ***** NONE n Tested By: Zac Gates Telephone: 817.685.0099 Fax: 817.283.1192 Web Site: Automabile Sta#ement of Values: Fund Member has provided the Fund with the most current and accurate statement of values for al! applicable property, including a complete and accurate lisfing of vehicfes owned by the Fund Member. Fund Member agrees to allow the�und to conducf property appraisals of the Fund Member's property on a periodic basis ancE agrees to accept vaiues provided by the Fund. Salvage: The Fund will have the right, in its sole discretion,to exercise rights of salvage to any damaged property paid for or replaced under the terms of this Agreement. Claims Reporting: Fund Memberwill pravide to the Fund timely notice of ai!claims as required in the Interlocal Participation Agreement and the Fund's Coverage Agreernent General Coverage: Coverage terms and limits provided are as set out in this CCS and the Fund's Coverage Agreement for this participation period. Definitions: Any terms not defined in this CCS will use the definition for that term fram the corresponding Fund coverage agreement. Payment: 7he �und Member agrees to pay canfributions based on a plan developeci by the Fund.Ali confributions are payable upon receipf of an invoice from the Func4.7he�'und shail determine the applicable progratn for each contribution, Termination under this Agreement of any program shall not affect the rerriaining pragrams. Termination: This CCS may be terminated by either party with termination to be efFective on any successive renewal date by giving written notice to the ofher party no later than 30 days prior to automatic renewai in accordance with Section 4(a)of the Interlocal Participation Agreement. If this CCS is not terminafed, the renewal CCS becomes effective on ti�e automatic renewal date and the member shall be bound by the terms of the renewal CCS. TASB Risk Management Fund Coppell ISD Au#o, Liability& Property CCS July 27, 2018 RP057922-204 8-1 � ' ALlTOMOBILE Limi# Deductible Contribufion Automobile Liabifity $100/$300/$100 $1,000 $1�0,000 per Person Bodily Injury Limits!$300,000 per Occurrence Bodily fnjury Limits/$100,000 per�ccurrence Property Damage Limits Automobife Physicaf Damage Comprehensive Actual Cash Vafue $1,000 Included Colfision Actuai Cash Value $1,000 included i"OTAL CONTRIBUTION This is not an Invoice. TASB Risk Management Fund Coppefl ISb Auto, Liability& Property CCS July 27, 2018 RP057922-2018-1 USA �� DRIVER LICENSE' rx ��:�� .�.4 , 4d DL 09113514 9 c�a55 CM - ,��;" ' � 4; �55 02/03/2018 4b ExP 09/22/2024 .�,..�� p � ooa 09/22/1961 �•�� ,BAILEY �DAVID LEE .-� ....,a 12828 TRIPLE H DRIVE �� ' „ , � BURLESON TX 76028-0000 �z Restrictions NONE ya end NONE �' i �s Hgt rJ�–�8�� s Sex M �s Eyes BLV ��-:�✓ ��^� s Do 09619880025023786936 � – _ --- -- —__�— — -- _.._..___-------•------ --�------_-,_-�-.,_.._,..-.._._ ' TEXAS GOMMISSION ON EN-1lIRQNMENTAL QUALiTY i � DAVID L SAILEY i � Is hereby licensed as a .� '� � � LICENSED�RRLGATOR ! � �,.I License Number Expires i ., � 008753 03/31/2020 /; /' , � ��y�� . � i � SIGNATURE EXECUTIVE DIRECTOR + — -----------------•--------_•------------------�----__---_------- �_ � � ——_– _---- • --- �� TEXAS COMMISSION ON ENVIRON.MENTAL QUALITY I DAVID L BAILE`�' i Is hereby licensed as a B.aC'IiFLO�'V i R�VENTION�SSEI�IBLY TESTER I � . � License Number �xpires f , , i BP00067�8 02/07/2020 ,' ��,�? �� ^ j�, • i — �,� <�—rt�C.� �1_ `I.)`�