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Mi LH FILE HECORD INFORMATION' )HM <br />SWELPS <br />ACI On co -only P r o g /Sub E l e m Cc�rtw No. <br />E.H. <br />P/S.E. <br />Local <br />Previous Comp, <br />tAumoc-n <br />L ---'1 <br />—1 <br />L I- <br />- <br />SATE RAME (30 ctwaclora) <br />Comp. Numhor <br />(assigned by clerk) <br />Su Dist. <br />Effective ogle <br />Done <br />Location CodeFee Ex. <br />�1 h <br />Other Program Activi ty <br />Pr C6 C r 0 r,,_- --s 6y✓ <br />SITE Address (no./Dir/Street/Suffix/Suite) Site City/State/Zi <br />PREVIOUS DBA <br />B i l l i nn rlame <br />Billing Address (No/Dir/S tree t/Suffix/Suite') Billira' City/State/Zinn <br />-7 0 6 Y- <br />OwPJEn HMAE (Oo cr)wacler]) . <br />ESt yLE <br />I Seats <br />Sq. Ft. <br />I Untts <br />`JTE TELEhsOr.C- M-IM0E14 <br />� NTIJ <br />0YYtgEnAddress (Ido./Dir/Street/Suffix/Suite) Crner City./State/Zip <br />SPECIAL PROGRAM INFORJIATION No. of S4rvlca <br />Connecilont <br />Ei� <br />. Ilealth��—�I Wate��I i <br />AUDI TIOhdAL CONMEI'lS <br />EII 01 15 <br />Source of Treatment Population, <br />Supply Type Served <br />L _._ <br />__ <br />San. Sup. AC aC <br />____a <br />