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MA4hFi FILE RECORD INFORMATION OHM <br /> SIDE S <br /> ACI K)n cow,tr P r o g/Sub E l e m Computes NO. u.�. <br /> ® �f 1�i± 0 1 Q 0 10-1,1kil <br /> E . H . (assigned by c erk) <br /> P/S . E . Local Com P . Number Su Dist . Location CodeFee Ex: <br /> IcC) zTe, el Z 10 -4 1 0 <br /> Previous Comp, NumBEA Effective oate Other Program Activity <br /> FF1 - 1 1 - 1 1 1 1 <br /> SITE NAME (30 ctwractor,) <br /> SITE Address (no./Pi r/Street/Suffix/Suite) Site City/State/Zi <br /> d,e,d"6 r.,q S. 0)= <br /> PREVIOUS ODA <br /> Billing Name _ <br /> Billing Address (No/Dir/Street/Suffix/Suite) BilliliQ' City/State/Zip <br /> 4 -Sit <•a� &o� _ � ,QCyE4,c_Z tl/cLs, cA c�o 2-11 <br /> E31 tlZE SITE TELEPt<*:E Nu►40VI <br /> M Seats <br /> ISNntts <br /> tt, o � % <br /> OWNER NAME 00 cnaractc 3) <br /> �Eo�J <br /> S, 0. <br /> owNEnAddress (iso./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> X33 s7-o�c-A--729"J, c4 �1.6—2Q 3 <br /> SPECIAL PROGRAM MFOP-MATION No.of Serv(ce source of Treatment Population <br /> _ Conneetlont supply Type Seryed <br /> Rdc. Ileal th bJa termsj , LLJ <br /> se'r19 <br /> ADDITIONAL C011NiEi JTS ; <br /> San. Sup. (AC <br /> EH of 15 H r�L,, i_._._.1 S <br />