TONY JACQUEZ City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
002390-0002 Debbie T. 02/11/2019 10:25AM
ENERGOV INVOICE
Jacquez, Tony (Ideal Fire & Security)
2019 Item: INV-19-00015302
Balance due: 0. 00
Balance unpaid: 0 .00
Backflow Contractor
Registration 75 . 00
Payment Id: 12676
--------------
75. 00
Subtotal 75. 00
Total 75. 00
CHECK 75 . 00
Check Number 024713
--------------
Change due 0 . 00
Paid by: Jacquez, Tony (Ideal Fire &
Security)
Thank you for your payment
CUSTOMER COPY
_ ��
7 H E • C i T Y • O F
��i �i../�L
h
`�d —�.,� ��'t'��.�yw �yh, g� ^�,.,: �'`���>`f,..
�
-� � ,+� .. .G^ t'
yu.. �.,:::
v' ) �
�' Y �; ��, ,�:s�' � y
.1 � , 1
BACKFLOW REGISTRATION FORM
Registration is for one year from the date of registration or re-registration.
Date of Registration: � , �-' I� ' �(-�I�'i
Name: 1 U� �� �-��U
Company: , ~ � �
Mailing Address: �X ' •� '� '
(Street&Numb r/PO Box, City,State and Zip)
Physical Address: �C."11 W��/ I I
(Street&Nu ber,City,State and Zip)
Office Phone Number: �,� ' ��� ' 1� U J
Mobile Phone Number: �,�' � I v U ' ��
E-mail Address: C� `
City of Coppell Public Works Dept.
816 S. Coppell Road
Coppell,TX 75019
972-462-5150
www.coppel Itx.gov
__� ��:. _..am..�