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MA i FILE HECORO INFORMATIONI <br /> S W E17'reT <br /> ICI Qn County P r o g/Sub E l e m Computer No. 0.01V <br /> ® 3 --z 1 71 10101TI [77Gs ff <br /> E .H . (assigned by clerk) <br /> P/� Local Comp . Numb Sup/Di s t .p Location ICodeFee Ex. <br /> y 1:10 ' U 7 lug <br /> Previous Camp, NuMoen Effective owe Other Program Activity <br /> Q �TT1-I�f G 7 1 1 / y [IZ� 1 <br /> SITE NAME (00 chwacio(e) _ <br /> J7�d E � C) Y, s <br /> SITE Address (no./Dir/Street/Suffix/Suite) Site City/State/Zi <br /> Par-k Dri ✓c I M a-, 1 -e cct G-A - 9S 33� <br /> PREVIOUS DDA <br /> L <br /> Billing dame <br /> -50,fyw-- CSS C� ova <br /> ( 8iillling ,Address (No/Dir/Street/Suffix/Suite) IBilling' City/State/Zip <br /> I r" 0 X '2-3� 1 ..L./�'I �� � � cls , ? 5- 3367— <br /> 'M <br /> 5336YI S EST yZE SATE TELCN Or.f NWOER <br /> / Seats <br /> I Units ~tU ` =,2- Lj <br /> OWNEn NMAE(00 ChwoCten) . <br /> OWNER Address (No ./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> E <br /> SPECIAL PROGRAM INFORMATION No. o(Serv(C! Source of Treatment Population <br /> Connet:!ont supply <br /> Type Served <br /> Rec. Ilcaith � 'dater L�_1___L�J <br /> ADDITIONAL COMMENTS : <br /> San. Sup. AC SC <br /> EII 01 15 El <br />