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Wli �I L& ILL hLL.UhLU INI-UHMAI IUN Fl* <br /> AGI,on County Prograin Compulur No. <br /> U. tsc <br /> (assigned by clerk) ! <br /> Local Como. No. Sup/Dist. Location Code FtmAniounl/orCork- Fee Ex. <br /> k1jL- kJ a [=-74T I [I <br /> Previous Camp. NUMBER Effective Date Other Program Activity <br /> _ Ll Ft I O / C% /T E <br /> SITE NAME (90 characlens) <br /> P16 der►n <br /> SITE Address (no./Bir/Street/Suffix/Suite) Site City/State/Zi <br /> 3030 Sf '0� <br /> PREVIOUS DBA <br /> Billing dame <br /> Billing .Address (No/Dir/Street/Suffix/Suite) Billing- City/State/Zip <br /> Program Element ESI SIZE SITE TELEPHONE NUMBER <br /> ® f1Seats <br /> 2 c� SqFt. <br /> b Units <br /> OWNER NAME (00 characters) . <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORINATION <br /> Rec. Health <br /> No. of Service Source of Treatment Population <br /> Program Element Connectlons r—S�pplyy Type Served <br /> Water 4 6 <br /> San. Sup. AC <br /> AC SC <br /> 1-1 / U <br /> F�,., [a--] w� <br />