Laserfiche WebLink
I 5i L•H FILE RECORD INFORMAL V FUHM <br /> SEEPS <br /> kion Camly P <br /> g7-S--u–b €1 e m Cceautw No. 11..w <br /> (assigned by cTcrk) � c7PH . <br /> Local Comp . Number Su Dist . Location CodeFec Ex. <br /> v � I o3F F/ El <br /> omP. NUMDER Effective Dais Other Program Activity <br /> SITE NAME (30 Uwacio(a) <br /> SITE Address (no./Dir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DOA <br /> OiIIincl Mame <br /> I Scats <br /> Sq Ft <br /> Billing .Address {No/pir/Street/Suffix/Suite) Oillil�g' City/State/Zip <br /> / JI CZE yiE TELfhgNE,NVMOEN <br /> IC Untts <br /> OWNER NWE (00cAwactef3j . <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> g <br /> SPECIAL PROGRAM INFORI1ATION No' <br /> ofService Source of Treatment Population <br /> Conneeliont Supdv (�Type Served <br /> Rec. Ifcalth wlater —�--�J FTF1 <br /> ADDITIONAL COMMENTS : <br /> San. Sup. C �7 Sr c,� -- <br /> ELI 01 15 n E -- <br />