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MA:,I LI ' ILL HLUUNU INhUHMAI IUN t-UFJ <br /> �.w <br /> f <br /> Action County NoVa'n Compuwr No. lt. ry <br /> (assigned by clerk) <br /> LO-cal Como. No. Sup/Dist. Locatun Code Fue Amount/orC Jx Fee Ex. <br /> FOMTE c l 11 <br /> Previous Camp. NUMBER Effective oate Other Program Activity <br /> SITE NAME (30 cheracle(e) 1 __ <br /> SITE Address (no./Dir/Street/Suffix/Suite) Site City/State/Zi <br /> ClUb Blue(- 10 lori <br /> PREVIOUS DBA <br /> Billing Blame _ <br /> ctTlling .Address (No/Dir/Street/Suffix/Suite) Billing- City/State/Zip <br /> �3`fL k' I'o <br /> /� <br /> Program Element EST WE r Seats s V SITE TELEPHONE NUMBERS e t�aa__S <br /> „«� �❑ <br /> Sq. Ft <br /> # . <br /> H Units <br /> OWNER NAME(30 characters) <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM IN FOWIATION <br /> Rec. Health <br /> Program Element No. of Service Source of Treatment <br /> Connections supgAy <br /> Type <br /> m Population <br /> Served <br /> Water 4 6 <br /> -or- 1986 -1- /097 <br /> San. Sup. AC Sc <br /> F� . o o- <br />