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I" ",TEH FILE HECONO INFOAMAT11C ` FOHM <br /> SIYLEPS <br /> ^<tPon Countr P r o g/Sub E 1 e m corrpulut No <br /> i -J 1�y <br /> E . H . (assigned by clerk) <br /> P/S . E . Local Comp . Plumber Su Di s . Location CodeFee' Ex. <br /> 1P, Nu [10 3 a SSI 0 <br /> Previous Comp. NUMoEn Effective ogle Other Program Activity <br /> n <br /> SITE NAME (00 chwracrore) <br /> SrTE Address (no./0ir/Street/Suffix/Suite) Site City/State/Zi <br /> [ /�,/",)- V- )0,- n <br /> rP/9 61, c 6e <br /> PREVIOUS DDA <br /> Billing Mame _ <br /> dilling ,Address (Ho/Dir/Street/Suffix/Suite) Billing* City/State/Zip <br /> ES1 �tZE `,JT'E TEIEF►sC*.E NV►.iUil <br /> � SCat� <br /> Sq. Ft, <br /> L", <br /> � t <br /> I Untts ' I E <br /> OWNER W ME (00 charxtc 3) . <br /> OWNERAddress (iJo ./Dir/Ctreet/Suffix/Suite) Owner City/State/Zip <br /> F- i i <br /> SPECIAL PROGRAM INFOR.'IATION No.of S•rYIca source of Treatment Population <br /> io�nfnee tons supply Type Se rued <br /> Rec. Ileal th /1a ter r j LLJ <br /> ADD TI OVAL COMMENTS : --- <br /> San. Sup. AC SC <br /> EII 01 15 [:1 <br /> 0 �17 <br />