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MAS' H FILL HLCOHD INFORMATION HM <br /> .A[Ign Coun(y Program <br /> Camputa No 11 � <br /> (assigned by clerk)- <br /> Local Come. No. Sup/Dist. Location Code Fee Aniounl/otCUrll Fee Ex. <br /> N <br /> � r, N S I 0 <br /> Previous Camp. NuwoER Effective pate Other Program Activity <br /> SITE NAME (30 characters) <br /> SITEAddress (no:/Dir/Street/Suffix/Suite) Site City/State/Zi <br /> s <br /> � PC) /C 5 0 <br /> PREVIOUS DBA <br /> c l 4, ��� C C:) — <br /> Billinq flame <br /> C G- / /yc <br /> dilling .Address (No/Dir/Street/Suffix/Suite) Billing- City/State/Zip <br /> P o f2 c� l PC/ �co C4 <br /> Program Ekment EST SIZE SITE TELEPHONE NUMBER <br /> Seats <br /> 3 O-R) Sq. Ft. <br /> M Units <br /> OWNER NAME (JO characters) . <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORMATION <br /> Rec. Health <br /> No. of Sarvlcs Source of Treatment <br /> ype <br /> Program Element Connections Supply T Population <br /> Seneed <br /> WATER 4 6 <br /> San. Sup.L1AC SC <br />