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M HLE RE=CORD INFORMAhON*H <br /> .Action Coin IY Program <br /> Cornpulrx No tt. <br /> (assigned by clerk) <br /> Local Come. No. Sup/Dist. Location Code Fen Amount/or Curti <br /> Fee Ex. <br /> = Nt., I uS d ► off' / � D / o] <br /> El <br /> Previous Comp. NUMBER Effective nate Other Program Activity <br /> SITE NAME (00 characters) <br /> �'u-s ?�rl«.1 �erVic � Corpdra��o� <br /> SITEAddress (no./Pir/Street/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DBA <br /> Billinq Name <br /> TYIAw; MOA .Ser U ee Car po rot ova <br /> Billing .Address (No/Dir/Street/Suffix/Suite) BillingCity/State/Zip <br /> Program Element Est SIZE Seats SITE TELE PttONE NumaEH U <br /> 2 3 ❑�❑ w< <br /> # Units � � <br /> OWNER NAME (30 characters) <br /> SerVl6sE ❑c) ra- !(�v� <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> P0, -x �S-3U 15yo"P , <br /> SPECIAL PROGRAM INFORMATION <br /> Rec. Health <br /> No. of Service Source of Treatment <br /> Program Element ype <br /> Connections supply Population <br /> WATER 4 6 � I I I I TServed <br /> m � <br /> San. Sup. AC SC <br />