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JASON HOLMES City of Coppell, TX Public Works 255 Parkway Blvd, Coppell, TX 75019 Coppell, TX 75019 972-304-3500 Welcome 002390-0001 Debbie T. 02/11/2019 10: 16AM ENERGOV INVOICE HOLMES, JASON (SOUTHWEST FIRE & SECURITY, LLC) 2019 Item: INV-19-00015300 Balance due: 0. 00 Balance unpaid: 0. 00 Backflow Contractor Registration 75. 00 Payment Id: 12675 -------------- 75.00 Subtotal 75.00 Total 75.00 CHECK 75 . 00 Check Number 9127 Change due 0. 00 Paid by: HOLMES, JASON Thank you for your payment CUSTOMER COPY T H E • G i..._.T Y • O F �+C�PP�LL �` ��� W�„�=�--'�`�:� �� o � �� � � � x „ � , � BACKFLOW REGISTRATION FORM Registration is for one year from the date of registration or re-registration. Date of Registration: �`` �� �� r�'^,' Name: ��c���� �,1 r I� J Company: ����WQS� ��Q. � � ��.�1�1 i �� MailingAddress: ��� ���5��� ����� �2�`C � 1� 1��5��� ��1�� � (Street& Number/PO Box, City,State and Zip) Physical Address: ��Q (Street& Number,City,State and Zip) Office Phone Number: �'�'`'[�� ' 'i'�S� Mobile Phone Number: 2 �"I "2�2 �Z�� E-mail Address: ���"V U�.�V � D�v�v�����'Ll�� � ��� City of Coppell Public Works Dept. 816 S. Coppell Road Coppell, TX 75019 972-462-5150 www.coppelltx.gov �