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M EH FILE RECORD INFORMATION -OHM <br /> SIRS <br /> Qxmt y P r o g/Sub E l e m Cor+puwr W, <br /> L3 ?1 41770 7 <br /> 10 � g <br /> j <br /> WCOMP, <br /> (assigned by clerk) too <br /> L cal Com . Number Su Dist , IOcation CodeFee E <br /> r � ct i s Q3 zI E NUMOv Effective Date Other Program Activity <br /> I c7 <br /> SITE NAME (30 chwaclori) <br /> 1.fid t C <br /> SITE Address (no:/Cir/Street/Suffi.x/Suite) Site City/State/Zi <br /> 2. <br /> L5 TD coo 9,9-13 3'7 <br /> PREVIOUS DBA <br /> Bill ing name <br /> �e -5 r9�a <br /> Billing Address NO/Dir/Street/Suffix/Suite) .8111Ing, City/State/Zip <br /> E51 WE SITE TELEMIONt:WUs4004 <br /> ,1 sears „(A t <br /> I J_ns�. Ft. 3 g 39_r7 �, 0 <br /> r Vntts <br /> OWNER NAME ar <br /> (oo chacters) <br /> O'+ NER Address (140./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORIMATION No.of S+ndco' Source of Tresiment Population <br /> Conntctlort� Supply Type Served_ <br /> Rdc. Health Lilater m <br /> ADDITIONAL C014MENTS <br /> San, <br /> ER 01 15 <br />