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MAti I—i_•F-ILL HE WHO INFOHMATIOI#HM <br /> x _ <br /> Nctbn Courtly Pr.wam Computes No. <br /> l 1, nr <br /> 3 <br /> EET p 1 ) [ FI-3 z, <br /> (assigned by clerk) <br /> Local Comc. No. Sup/Dist. Locaaon Code Few Alitt)Un1/or CLx1. Fee E X. <br /> FFTT T-F <br /> D <br /> Previous Comp. NUM13ER 'Effective oats Other Program Activity <br /> U <br /> :LTI- <br /> SITE <br /> NAME (30 characte(s) <br /> �0 <br /> SITE Address (no./Vi r/Street/Suffix/Suite) Site City/State/Zip <br /> 26 <br /> PREVIOUS DBA <br /> Billing dame <br /> idilling, .Address (No/Dir/Street/Suffix/Suite) Billing, Cit /State/Zi <br /> • zo <br /> Program Element EST SIZE SITE TELEPHONE Num8EH <br /> # Seats <br /> Sq. F I C-] 7 JP] <br /> # Ott; <br /> OWNER NAME(30 characters) . <br /> OWNERAddress (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> F— Va A-) 4) <br /> SPECIAL PROGRAM INFOR!tATION <br /> Rec. Health <br /> No,of Service Source of Treatment Population <br /> Program Element Connections Supply Type <br /> Served <br /> WATER 4 6 DD <br /> San. Sup. AC SC <br /> D - <br /> D D <br /> 1 <br />