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N1A011 ILL HLUUH(J INf-UHMAI1UNom <br /> Action County Program Conpulw No. 11. rk <br /> (assigned by clerk) <br /> Local Come. No. Sup/Dist. LocatronCode FW Anruunl/or Cala Fee Ex. <br /> �. s = 0 2 T"1 11 <br /> Previous COMP. NUMBER Effective Dale Other Program Activity <br /> SITE NAME (90 characte(s) <br /> SITEAddress (no./Dir/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 ESI SIZE SITE TELEPHONE NUMBER <br /> SeatswK� <br /> Sq. Ft. <br /> 12131-& # Units <br /> OWNER NAME (00 characters) <br /> OWNER Address (tJo ./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORNATION <br /> Rec. Health <br /> No.of Service Source of Treatment Population <br /> Program Element Conneetlom Supply Type (�7Served <br /> Water 4 6 m <br /> San. Sup. AC SC <br />