Rodney Miller City of Coppell, TX
Public Works
255 Parkway Blvd, Coppell, TX 75019
Coppell, TX 75019
972-304-3500
Welcome
002522-0002 Debbie T. 03/Ol/2019 02: 18PM
ENERGOV INVOICE
Miller, Rodney (Berryman Fire)
2019 Item: INV-19-00015596
Balance due: 0. 00
Balance unpaid: 0. 00
Backflow Contractor
Registration 75 . 00
Payment Id: 13147
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75.00
Subtotal 75. 00
Total 75. 00
CREDIT CARD - UTILITY OPS 75 . 00
AmeriCdn Express ************2030
Ref=3219625201
Auth=886955
201903015Al2
AID=A000000025010801
Invoice=78200620190301141739
AuthCode=886955
Entry=Chip Read
AppLabel=AMERICAN EXPRESS
ATC=003D
Seq=78200620190301141739
--------------
Change due 0. 00
Paid by: Miller, Rodney (Berryman Fire)
Signature:
Thank you for your payment
CUSTOMER COPY
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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 � � I � � � l
Name: l�o d rV L� M � �.C� �K
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(Street&Number/PO Box, City, State and Zip)
PhysicalAddress: �� Z � �1/(JT� .��s���qp�v/ /�j; �x '� �`��
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Office Phone Number: 2 ��I ' 3 ,3 �^ �j �L �j
Mobile Phone Number: ���-/ ' Z�� - �j� �G
E-mail Address: � E/ele}l�`1/( i�{!� F�iP�' � SQ� � 1 U �'�L � T
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