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MASOFILE RECORD INFORMATION <br /> �Accttoon} Counly Program Corpulur No. <br /> 0 0 111 ?- 3 � � <br /> (assigned by clerk) <br /> Local Como. No. Sup/Dist. locatronCode FouAelrUuml( Cut), Fee Ex. <br /> 0 / 1 1 ITT T I L-1 <br /> Previous Comp. NUMBER Effective pate Other Program Activity <br /> _ _ I <br /> SITE NAME (30cheraclera( <br /> s,-i, <br /> /� <br /> /1 O4L4,1✓", LCD. WLISdh WQyne)e, <br /> SITEAddress (no./Vir/Street/Suffix/Suite) Site City/State/Zi <br /> 41Ll el 5, 6V/115 0r,, 72a 1CY-o h <br /> PREVIOUS DBA <br /> Billing Blame <br /> h Ja <br /> Billing .Address No/Dir/Street/Suff x/Suite) Billing- City/State/Zip <br /> zzZ T—:- r -5-4 , I <br /> Program ELment �ES1 f SIZE SITE TELEPHONE NUMBER Mn <br /> N# Seats <br /> �Units NK. . FLAW <br /> OWNER NAME (00 characters) . <br /> , <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> J <br /> SPECIAL PROGRAM INFOR;IATION <br /> Rec. Health <br /> No.of Service Source of Treatment Population <br /> Program Element Conneetlont supply <br /> Type Served <br /> Water —]:4:= �—� M <br /> San. Sup. AC Sc <br /> 1-1 ff I �R1 <br />