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MASA FILE RECORD INFORMATION FOAM <br /> Action County Prapam Computer No. 0 ire <br /> .1• <br /> ® 3 � 3 0 UUU7 <br /> (assigned by clerk) <br /> Local Come. No. Sup/Dist. LocatronCode Fee Arrmwnt/orCode Fee Ex. <br /> o. N N 0 1 `l / IMI /3 - L__l <br /> Previous COMP. NUMOER Effective Date Other Program Activity <br /> - D. A 10 !J q1 I © Z _ <br /> SITE NAME (00 characters) <br /> -I <br /> st EAddress (no:/Dir/Street/Suffix/Suite) Site Cit /State Zi <br /> PREVIOUS DBA <br /> Billing name <br /> s J <br /> Billing Address (No/Dir/Street/Suffix/Suite) Billing City/State/Zip <br /> � ZA <br /> Program Element EST SIZE SITE TELEPHONE NUMBER <br /> S9Ft <br /> Seats <br /> 3 b L—LW <br /> III Units <br /> OWNER NAME (30 characters) . <br /> OWNER Address (140./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL. PROGRAM Ii ORMATION <br /> Rec. Health <br /> No. of Service Source of Treatment Population <br /> Program Element Connections Supply Type <br /> m Se rued <br /> 4 li <br /> San. Sup. ACC Sc <br /> F01... Q u I�.:� I 1�l <br />