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Gluarado, Boanerges City of Coppell, TX Public Works 255 Parkway Blvd, Coppell, TX 75019 Coppell, TX 75019 972-304-3500 Welcome 001945-0001 Debbie T. 11/20/20i8 10: 58AM ENERGOV INVOICE Gluarado, Boanerges (DSS Fireguard, Inc) 2018 Item: INV-18-00013043 Balance due: 0. 00 Balance unpaid: 0 . 00 Backflow Contractor Registration 75 . 00 Payment Id: 10537 -------------- 75. 00 Subtotal 75.00 Total 75. 00 CREDIT CARD - UTILITY OPS 75 . 00 Visa ************9113 Ref=2442778201 Auth=02297G 201811209F61 AID=A0000000031010 Invoice=78200620181120105741 AuthCode=02297G Entry=Chip Read AppLabel=VISA CREDIT ATC=0010 Seq=78200620181120105741 -------------- Change due 0. 00 Paid by: Gluarado, Boanerges (DSS Fireguard, Inc) Signature: Thank you for your payment CUSTOMER COPY ______�._..___.____.._.,__ T H E • C 1 T Y • O F �C�PP�LL � .� , f� .. � � .,:. T '�. � �,. � �.e: £ x ;��'�� a � ✓ � A 5 . 1 BACKFLOW REGISTRATION FORM Registration is for one year from the date of registration or re-registration. Date of Registration: _, --�� Name: r�7�� ; � �-°� C� �_.,��; i i, �:_'c<_ , � ��. r Company: �� i f`��.=��.,rCk- .-�n-=C� . MailingAddress: `� �. w��`:. "�. -�.`�C~�C�.�� c� �f'< 5 � � ��.��.SJf �6�� (Street& Number/PO Box,City,State and Zip) Physical Address �-� �;C'•,�. /�,c: "f � ��r�,� t� f �C� c=r' �'�c�_r'!�z•"�c� r�k�. ��:' '� � (Street&Number,City,State and Zip) Office Phone Number: ,� ( `-f ' ,� `� � � 7/L'��' �: k�% j C�� ,� �s � Mobile Phone Number: �� =� � � � � �.'�' ��E�� E-mail Address: Y� ��-��'� 5 � `��f��.-C; U�� t� F ��U/�'( City of Coppell Public Works Dept. 816 S. Coppell Road Cvppell,TX 75019 972-462-5150 www.coppelltx.gov �