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I ILL HLL UhL) IN�-UfIMAI JUN M <br /> Myon County Pr <br /> o(yarn Compulwr No. <br /> tl. r"r <br /> n-.I? IEE <br /> (assigned by clerk) <br /> Local Come. No. Sup/Dist. locakmCode Fou CLXk <br /> aFO—PT/71 Fee Ex. <br /> � I <br /> 1 <br /> Previous COMP. NUMBER Effective Date Other Program Activity <br /> J EL:EE--Lr—L—1 <br /> SITE NAME (30 characters) <br /> SITE Address (no./Dir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DBA <br /> Billing Name <br /> ------------ <br /> 8illin Address (No/Dir/Street/Suffix/Suite) Billing' Cit /State/Zi <br /> J <br /> Program Element ESI S+ZE� <br /> SITE TELEPHONE NItMBEH <br /> $eats NKA <br /> Sq. Ft. <br /> # Un lt is � 17 11 1 1 1 1 1 <br /> OWNER NAME (30 characters) . <br /> OWNERAddrEss (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFOR'.1ATION <br /> Rec. Health <br /> Program Element No. of Service _ Source of Treatment <br /> Connections Supp? TYPe Population <br /> LLJ <br /> Served <br /> San. Sup. AC SC <br /> 0 DIV <br />