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MAJEt 'S•H FILE RECORD INFOAMAT4o HM <br /> 54 <br /> Acton coinl r P r o g/Sub Clem Computer No. <br /> 2 � 3 0 0 <br /> E . H . (assigned by clerk) <br /> P/S . E , Local Com Number Su Dist . Location Code Fee Ex. <br /> LC 5 -31 <br /> :2 10 1 <br /> Previous Camp. Numom Effective oate Other Program Activity <br /> FF I I I I I- 1 0171 01 � I F M T I T I <br /> 517E NAME (30 chwactora! <br /> C;1/-C-Ul14- W01-k-5 <br /> SJTE Address (no:/Dir/Street/Suffi.x/Suite) Site City/State/Zi <br /> lrlles-t" Ci 1� S4-0C.LOve G4 175�206 <br /> PREVIOUS DOA <br /> Bi I l i na NAme <br /> 5 a'y� C�-5 o V-P-- <br /> Billing ,Address (iia/Dir/Street/Suffix/Suite) BillirgrCity/State/Zip <br /> S�Yne a S On o V�-- <br /> n s EST �S+XE WE TEt.Eh+O+C- MA V4 <br /> Sams <br /> Untits �- _3 ol Ic. lo <br /> t WNE-n NWF. (00 CrWaclsra) . <br /> OWNER Add re;ss (too./Di r/Street/Su(fi x/Sui te) Owner City/State/Zi p <br /> SPECIAL PROGRAM INFORMATION No. of Sanr(te Source of Treatment Population <br /> Connect(onl supply Type Se rued <br /> Ric. health ,,tater FTJ <br /> ADDITIONAL COMMENTS : <br /> San, Sup. QAC Scc—,—� <br /> EIS 01 15 I( i n E:] til J <br /> ! <br />