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MAS { FILE RECORD INFOHMATION.*M <br /> Act - <br /> i Coumly F'ro(watn <br /> C xnputtx No. <br /> L <br /> Local Comc. No. (assigned iby clerk) <br /> Sup/Dist. Locatan Code <br /> Feu Ai►xxml/or Cuck Fee Ex. <br /> Previous COMP. NUMBER I l <br /> Effective Date Other Program Activity <br /> L I <br /> SITE NAME (30 characters) - <br /> -----�— <br /> SITEAddressno. I <br /> ( /Pir/Street/Suffix/Suite) Site City/State/Zi <br /> �� . <br /> PREVIOUS DBA <br /> Bi 11 i <br /> n Name <br /> ra� Idilling AddressN <br /> ( o/Di//r/Street/Suffix/Suite) Billin Cit /State/Zi <br /> Program Element <br /> ESI SIZE <br /> SITE TELEPHONE NUMBER <br /> # Seats <br /> Sq. Ft. 2 KCS <br /> # Units <br /> OWNER NAME (30 characters) <br /> 1 <br /> OWNER Address (Wo ./Dir S I <br /> / treet/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORMATION <br /> Rec. Health <br /> No. of Servicrt - _ -------- <br /> Program Element Source of Treatment <br /> Source <br /> Supply Population <br /> WATER 4 g Type Served <br /> San. Sup. AC SC <br /> FAV <br /> ( El <br />