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Ni1bIjp-ILL I-3t=C;OHD INF=OI{NATION F4W <br /> I <br /> 1-Ct,U1 Gounty Pr(xyarn Compulur No <br /> (assigned by clerk) <br /> Local Comc. No. Sup/Dist. Local*nCof1e Feu Anux,ni/ofCLxke Fee Ex . <br /> Q- FT-1- L <br /> i <br /> Previous COMP. NUMBER Effective pale Other Program Activity <br /> SITE NAME (30 chat 3Ctere) <br /> SITE ddress (n ./Vir/Street/Suffix Suite) Site City/State/Zi <br /> PREVIOUS DBA _ <br /> Billing Fume <br /> Billing Address (No/Dir/Street/Suffix/Suite) BiIIing' Cit /State/Zi <br /> F-' <br /> Progfam Elefnent E51 SrZE SITE TELEPHONE NUMBEH <br /> # Seats AIKA <br /> FT- <br /> Sq. FtT- 1:: . <br /> # Units 7 11 t <br /> OWNER NWE (30 characters) . <br /> 4, <br /> OWNER Address (No ./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFOR'3ATION <br /> Rec. Health <br /> No. of Service - - -Source of Treatment Population <br /> Program Element Connectlons Supply Type Served <br /> WATER. 4 1 6 <br /> San. Suo. AC SC <br /> n <br />