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W1AJ { I ILL HLWHU INF-UHMAI IUN h iM <br /> Actgn County© Program Compulur No. '. <br /> 3 3 �- <br /> (assigned by clerk) <br /> Local Comc. No. Sup/Dist. Location code Feu /unount/orC jL. <br /> Fee Ex. <br /> EIlaY& El <br /> Previous Camp. NUMBER Effective Owe Other Program Activity <br /> _ �/I /. I L I Ili F � O ELI= _L_t__ <br /> SITE NAME(30 characters) <br /> s+TE Address (no./pir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DBA <br /> Billing flame <br /> Billing .Address (No/Dir/Street/Suffix/Suite) Billin , Cit /State/Zi <br /> Program Element / SITE TELEPHONE NUMBER <br /> Z 3 fY eats <br /> Y S . F <br /> IY Units <br /> SIZ <br /> OWNER NAME (30 characters) . <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORIiATION <br /> Rec. Health <br /> No. of Service Source of Treatment <br /> Program Element Connectlont supply Population <br /> Served <br /> Water <br /> 4 6 Tm � <br /> San. Sup. AC Sc <br /> F/... ❑ ❑ Ea - ®r <br />