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MA,t#d HL.L HLC:OHD INFO) WMION <br /> M <br /> C'OUnIY <br /> Prow Jin <br /> Cornpxdur No <br /> EN, <br /> ZEE <br /> �. ++ <br /> Local Como. leo. Sup/Dist. (assigned by clerk) <br /> rt_ocalior►Code Fuu Ar,K,unl/a (.uekr Fee Ex. <br /> pDiPrevious Camp. NUMBER <br /> Effective Bate Other Program Activity <br /> ........... A ,= I � � ''I I I <br /> SITE NAME {30 characters} �« <br /> SITE Address (no./Pi r/Street/Suffi <br /> x/Suite) Site Cit /StateCZi <br /> PREVIOUS DBA <br /> Bi l l i r. raame <br /> dilling Address (No/Dir/Street/Suffix/Suite <br /> Bill , <br /> n Cit /State/Zi <br /> f <br /> r <br /> J '? <br /> Program Ekxnenl EST SIZE <br /> Seats SITE TELEPHOt4E NUMBER <br /> 12�MFO Sq. Ft. <br /> OWNER NAM # Un l tS <br /> E= <br /> E {Bo characters} . <br /> OWNERAddre-s (Ida ./Dir/Street Suff' <br /> / T x/hut te) Owner City/State/Zi p <br /> SPECIAL PROGRAM INFOW-1ATIO'N k <br /> Rec. l�eai th _ <br /> Program Element No. of Service <br /> ent Connections Source of Treatment <br /> Supply Population <br /> WATI;It 4 g TypePopulation <br /> Eu <br /> San. Sup. AC <br /> SC i <br /> � f <br />