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,.u�.,�t•► ILL r iLI,UNU INF-UHMAI IUN M <br /> .&ction . <br /> DounIY Program - . . ,ComP,�t,x No. <br /> 3 <br /> 5 "� I <br /> (assigned by clerk) <br /> Local Como. No. Sup/Dist. loc:danCode <br /> F,w Anrcrunt/or C �k Fee E x. <br /> I , EUIE E=57 <br /> mLl [I I <br /> Previous Comp. NuwER Effective vale <br /> Other Program Activity <br /> LLLL ' I <br /> SITE NAME (30 characters) <br /> SITE Address (no./Pi r/Street/Suffix Suite <br /> ) Site City/State/Zi <br /> PREVIOUS DBA <br /> Billinq Blame <br /> Billing Address (No/Dir/Street/Suffix/Suite) Billing- City/State/Zip <br /> Program Element EST WE <br /> SITE TEIEPt-LONE NUAtigEH <br /> # Seats MEA <br /> Sq. Ft. <br /> N Untts T71 <br /> OWNER NAME (30 characters) . <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORMATION <br /> Rec. Health <br /> Program Element No. of Service Source of Treatment <br /> Connection, SupplyPopulation <br /> Type Served <br /> WATER 4 g ❑� <br /> San. <br /> Sup. AC SC <br />