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MAJ' I FILL HL.COHD INFOHMAIION F M <br /> -Action CamIY Nowain ' <br /> CMrpulw No <br /> 0� <br /> 3 <br /> 01, 0 <br /> (assigned by clerk) <br /> Local Como. No. Sup/Dist. Locat"iCode Feu Ati r nlror Cu<lu Fee Ex. <br /> E J <br /> Previous Comp. NUMOER Effective nate Other Program Activity <br /> - � I <br /> SITE NAME (90 characte(s) <br /> SITE Address (no./[sir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DEA <br /> Billir. Name <br /> Billing .Address (No/Dir/Street/Suffix/Suite) Billin - Cit /State/Zi <br /> l(� Y 1 <br /> i <br /> Program Element JJZE SITE TELEPHONE NUMBEN <br /> j (� Sq. Ft. <br /> M Units <br /> OWNER NAME (30 characters) <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORNATION <br /> Rec. Health <br /> No. of Se"Ice Source of Treatment <br /> Program Element ConnectlonfPopulation <br /> SupdY <br /> Type Served <br /> WATER 4 6 <br /> San. (Sup. AC SC <br /> FO... ❑ I _ r-1 IJ . <br />