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MA FILL HE GORD INFOHMArION M <br />4clion County PfojY'a#n CoTtputcq No <br />0 <br />1 '5F)T? EUT 70 <br />Local Come. No. <br />Previous COMP. NUMBER <br />SITE NAME (30 characters)__ <br />SITE Address <br />PREVIOUS DBA <br />(no./Pir/Street/Suffix/Suite <br />(assigned by clerk) <br />Location Code Fou A#vK)uril/(x C(Xk. Fee Ex. <br />LJJT7 <br />El <br />Effective -Date Other Program Activity <br />I <br />— L <br />Site City/State/Zi <br />......... .. .. . <br />t) i i I 1,Rg <br />ri a me <br />op <br />Z <br />Billing , Address (No/Dir/Street/Suffix/Suite) Billing-City/State/Zip <br />fi <br />by7 <br />e— A --r— <br />Program Element <br /><� id <br />OWNER NAME (30 characters) <br />EST 6A 1 SITE TELEPtiONE Numwi <br /># Seats AKA J <br />L <br />Sq. Ft # Units <br />X�a <br />:)WNERAddrcss (t4o./Dir/Strppt/(,iiffiy/riii*nI 172 <br />San. Sup. AC SC <br />F11-.0 1:1 0 0 [91 <br />op <br />SPECIAL PROGRAM IiqFORP.IATION <br />Rec. Health <br />Program Element <br />-L <br />No. of Service <br />Connections <br />Source of <br />Supply <br />Treatment <br />Type <br />Population <br />WATER 4 <br />T1 <br />L <br />Served <br />San. Sup. AC SC <br />F11-.0 1:1 0 0 [91 <br />