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MA•``TEH FILE RECORD INFORMATION FONM <br />ACIKn SlJ9S • <br />CO> ^I r P r o g /Sub E l e m Coc* NO. <br />C� o <br />E.H , (assigned by clerk) <br />Local Com n. Number Sun/Dist. <br />C ,41,QT,'41,,41177 a r <br />Pr 66 / Camp. r4uMocn Effective once <br />�� '' 1 r nn <br />Z G <br />H . ... .... ......... .......... i <br />S- Vp) <br />TE NAME 400 chnracto(i) <br />s+TE Address (no. 0i r/Street/Suffix/Sui te) Site City/State/Zi <br />AJAVy )A- <br />ril <br />Location CodeFee Ex <br />�I <br />Other Pr am Activity <br />Ll L <br />STo� K.To.�J <br />PREVIOUS DOA -'d- --rl 7`7 (0 <br />Sillin9 NAme <br />Billing Address (Ko/Dir/Stree t/Suffix/strtta) <br />S•4.Y� ,� .4�sov� <br />OrvrvER NAME (30 cnLa w3j . <br />EST SIZE <br />! Seat - <br />Sq - <br />eatsSq. Ft. <br />I Unl' is <br />Billing' City/State/Zi <br />9TE TElL•Pt0�.E Nt. 40CH <br />vro;- <br />6 7 ie> -1-371 <br />OWNER Address (Ho./Qin/.Street/Suffix/Suite <br />Owner City/State/Zip <br />SPECIAL PROGRAM Ii1F0"TiGN ko.01S4rvtei <br />sourctof <br />Treatment Population <br />Co�r+eella►1 <br />Su p d v <br />Type Se ry ed <br />Rdc. Ileal th <br />dater <br />ADDITIONAL COMMENTS;', , <br />OWN" <br />4i <br />Ell 01 15 <br />AC Sr, <br />