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Mr :H FILE RECORD INFORMATIO HM <br /> SWE,-r,S <br /> ^c t•on Co-ont y P r o g/Sub E l e m C TV%"No. <br /> rT <br /> 7 <br /> W .3 C/ 0 0 6 <br /> E . H . (assigned by clerk) <br /> P/S . E . Local Com . Number Su Dist . Location CodeFee Ex. <br /> L—=" L- aI Q3 � 7 1 0 <br /> Previous Camp. NUMOER Effective oat@ Other Program Activity <br /> L- 1 I ITH 1 1017-10111 8 U II I <br /> SITE NAME (00 chwacto(e) <br /> SITE Address (no./Vir/Street/Suffix/Suite) Site City/State/Zi <br /> L CA <br /> PREVIOUS DDA <br /> Billing game _ <br /> �.�. - Q5 <br /> dilling Address (Ko/Dir/Street/Suffix/Suite) Billing City/State/Zip <br /> bo ve- <br /> ES1 CZE &TE TEIL•Pt Or:E NWOEH <br /> ISScats N<A ; <br /> Ft, <br /> I%nlits �--•�- <br /> OwNEF1 RAME (000WOCter3) . <br /> F- <br /> CWNERAddress (iso ./Dir/Street/Suffix/Suite) Owner City/State/Zi p <br /> SPECIAL PROGRAM INFORIMATION No.of S.rvlco Source of Treatment Population <br /> Conrwilont supply Type Served <br /> Rdc. Health Jater <br /> ADDITIONAL COMMENTS : <br /> San. Sup. AC �C <br /> EII 01 15 El El � K <br />