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MA51e FILE RECORD INFORMATION FOM <br /> Acton County Program <br /> OOrrpultx No. I l <br /> &Tgi FA-31 10 1- <br /> 111. <br /> (assigned by clerk) 3 " <br /> Local Comc. No. Sup/Dist. Locator%Code <br /> Fuu Aniuunt/a Crxk: <br /> Fee Ex. <br /> o <br /> Previous Camp. NUM13ER Effective Date <br /> Other Program Activity <br /> o(I /< I Y moi_ <br /> SITE NAME (00 characters) <br /> ' Slams ,EP(-hzf� of <br /> s+TE Address (no./[sir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DBA No UJ � 1 <br /> a,,,, — I C �) _ SSU CAL <br /> CU N�ct_`_ G 1'1 31 <br /> Billin Name <br /> Billing .Address (No/Dir/Street/Suffix/Suite) Billin - Cit /State/Zi <br /> Program Element ESI SIZE SITE TELEPHONE NumoEH <br /> O / ❑❑ # Seats <br /> ❑ #Units wK. <br /> OWNER NAME (00 characters) <br /> OWNER Address (IJo./Dir/Street/Suffix/Suite) owner City/State/Zip <br /> SPECIAL PROGRAM INFOWIATION <br /> Rec. Health <br /> Program Element No. of Servlca Source of Treatment <br /> Connections Supply Population <br /> Type Served <br /> Nater 4 8 ❑� m <br /> San. SupAC Sc <br /> ro .. F] �g. o— rT <br />