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MAW i L-H FILE RECORD INFORMAL IUN F ORM <br /> S <br /> 7cton County P r o y/Sub E l e m CorIXAw No, <br /> H . (assigned by clerk) <br /> P/S • E . Local b e r Su Dist . Location CodeFee Ex <br /> 2 Ei I I 10 1 -? 1203 1 0 <br /> P amp. tiuMoen Effective oate Other Program Activity <br /> IT 1 L <br /> SITE NAME (30 chwacto(a) <br /> SITE Address (no./Vir/Street/Suffix/Suite) Site City/State/Zip <br /> f <br /> PREVIOUS DDA <br /> i - <br /> Billing Address (No/Cir/Street/Suffix/Suite) Billit.g' City/5tate/dip <br /> L--L�_— - i <br /> ESS SJ1E WE TELEN<*�"40E4 <br /> ion s X Seats <br /> Sq. Fc. � � � Ed <br /> �, � s y ; <br /> I Units <br /> OWNEFl NAME (30 crwactew . <br /> orvNER Address 040./Dir/Street/Suffix/Suite) Owner City/State/Zi p <br /> SPECIAL PROGRAM INFORINATION No.of ServteSource of Treatment Population <br /> conneetlont Supply , Type Served <br /> Rdc. Ileal thF -71- <br /> dater <br /> ADDITIONAL CONNIENTS : <br /> V �.___ <br /> San. Sup. ACSC <br /> d� �1 <br /> EII O? 15Fj rog—ip <br /> RIM— <br /> I <br />