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t <br /> Tw � EH FILE 1 F TIO 110 KPS qw <br /> KIS Ca,ntr P ro g/Sub E 1 e m w No.L 0 <br /> 1,.mnr <br /> - <br /> E .H . (assigned by clerk) <br /> P/S . E . Local Comp . Number Su Dist . Location CodeFe' Ex'. <br /> Previous Comp. r,umom Effective oate Other Program Activity <br /> LL-t --L . I ------F-TT KiAdi U0 <br /> SITE NAME 130 ctuuacto(r) <br /> Q <br /> SITEAddress (no:/Cir/Street/Suffix/Suite) Site City/State/Zi <br /> th ' <br /> PREVIOUS DDA <br /> Billing Blame <br /> r r r <br /> Billing ,Address {Ho/Dir/Street/Suffix/Suite) Bill iny° City/State/Zin <br /> 0 <br /> EST SIE SITE TEUPtior;E tvt. 40CIt <br /> as <br /> Sq. Ft, <br /> Units <br /> OWNE F1 NAME(30 crwacw3) <br /> OWNERAddress (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORSMATION No.ofService' Source of Treatment Population <br /> Connet-tions supply Type Served <br /> Ric, Health [/I�aterL_Lj <br /> ADDITIONAL COMMENTS <br /> San, sup° C dC <br /> EIi 01 15 F—ER 19 <br />