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rvV%%j I L10LL HLI UHU INFUHMAI IUN FUFO <br /> Acton County Program Carputof No. 1)..tv <br /> ® 3 2 3 p 4. <br /> (assigned by clerk) <br /> Local Comc. No. Sup/Dist. Location Code Feu AnwwnlrorCtxk Fee Ex. <br /> Previous Comp. NUMBER Effective nate Other Program Activity <br /> I I I <br /> SITE NAME (30 characle(a) <br /> SITE Address (no./Bir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DBA <br /> Billing Name <br /> Billing .Address (No/Dir/Street/Suffix/Suite) Billing- City/State/Zip <br /> Program Element EST SIZE raE NU <br /> r# S <br /> SITE TELEPMOMBERats <br /> 3 NgUnits w<. <br /> OWNER NAME(JO characters) <br /> OWNER Address (14o./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFOR,11ATION <br /> Rec. Health <br /> No. of Se"Ice Source of Treatment Population <br /> Program Element Connections supply l� Type �Servedd <br /> Water 4 6 1�1 1 FTI UPJ <br /> San. AC SC <br /> FA.., D � F/I w <br />