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u4 It a ILL I iLL UHU INFUfIMAI IUP' ' 14M <br /> clion - C;a!+n1Y Prp{pam - .Corrtprtw No. <br /> M:il. 2 3 o I <br /> (assigned by clerk) <br /> Local Comc. No. Sup/Dist. Loca(p„� FumMrK,,,Mja �k. <br /> I Fe�x. <br /> A l 0 ( ;� I <br /> Previous Comp. NUMBER Effective Bale Other Program Activity <br /> SIIE NAME (00 characters) �_ <br /> SITEAddress (no./Dir/Street/S fix/Suite) Site Cit /State/Zi <br /> PREVIOUS DBA <br /> Billing fume <br /> Billing .Address (No/Dir/Street/Suffi /Suite) Billin Cit /State/Zi <br /> LE2 / <br /> Program Ek,nent EST 511E SITE TELEPrgroE tAimeEH <br /> A Seats <� <br /> S9• Ft. <br /> N Un{ts <br /> OWNER NAME (30 cfuracters) <br /> OWNERAddress (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORMATION <br /> Rec. Health <br /> Program Element No. of Se"Ice Source of Treatment <br /> Connectlona Supply TPopulation <br /> m � <br /> served <br /> WATER 4 6 <br /> San. Sup. AC SACC <br /> E �I—] I1� <br />