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iv1/w it ILL HLI.UHU INFUHMAI IUN h (M <br /> Action County Program Computer No. ll.,ry <br /> MIYI 11 Iwr .1 r . <br /> -4 3 EE <br /> (assigned by clerk <br /> Local Como. No. Sup/Dist. Location Code F" Amlwnt/o( Cuk- Fee Ex. <br /> d i L l <br /> Previous Camp. NUMBER Effective Date Other Program Activity <br /> L <br /> SITE NAME (30 characters) <br /> SITEAddress (no./(sir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DBA <br /> _ <br /> Billing flame <br /> Billing .Address (No/Dir/Street/Suffix/Suite) Billin " Cit /State/Zi <br /> Program Element T1+ <br /> SITE TELEPHONE NUMBER <br /> # Seats <br /> -15C S Ft. wK. <br /> M�Units <br /> OWNER NAME (30 characters) . <br /> OWNER Address (tJo./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> 7/� C/Ea <br /> SPECIAL PROGRAM INFORMATION <br /> Rec. Health <br /> No. of Se"Ics Source of Treatment Population <br /> Program Element Connections Supply Type <br /> Water <br /> San. Sup. AC <br /> SC <br /> RP n El IKTI <br />