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MA,��R FILL RECORD • <br /> Acuou - Cwnty Program <br /> a 3 m FoTc <br /> (asst ( " <br /> Local Comc. No. Sup/Dist. t� �1 Fee Ex. <br /> I ( , - O ,j <br /> Previous Camp. NUMBER Effect ctivity <br /> SITE NAME (30 characters) <br /> � I � <br /> SITE Address (no./Dir/Street/Suffix/Suite? Site City/State/Zip <br /> PREVIOUS DBA <br /> Billing name <br /> dilling .Address (No/Dir/Street/Suffix/Suite) Billing- Cit /State/Zi <br /> Program Element EST SIZE SITE TELEPHONE NUMBER <br /> # Seats <br /> Ft <br /> ® 89Untts N . <br /> OWNER NAME(30 characters) . <br /> i <br /> i ' <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORtlATION <br /> Rec. Health <br /> Program Element No. of Service Source of Treatment <br /> CLD <br /> l Population <br /> Connections supply Type� m � <br /> 4 6 <br /> San. Sup. AC SCC <br /> L`< J IJ <br /> I <br /> FII.. <br />