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MAS 00E RECORD INFORMATION Fft <br /> Action County ProUrarrl <br /> Coqputw No. l):'rrr <br /> • �❑ <br /> 3 9 Z 3 Q 01?13 <br /> �r� �� <br /> 3 <br /> (assigned by clerk) <br /> Local Como. No. Sup/Dist. Location code Ftm Amount/or Cuda Fee E x. <br /> LO I �1 [01 / 1 1 V)1 .1 El <br /> Previous Comp. NUMBER Effective Date Other Program Activity <br /> SITE NAME(30 characters) <br /> L Z�- -21� --/� / <br /> SITE Address (no./lei r/St eet/Suffix/Suite) Site City/State/Zi <br /> PREVIOUS DBA <br /> Billing dame <br /> Billing Address (No/Dir/Street/Suffix/Suite) Bi111ng- Cit /State/Zi <br /> 19� <br /> -- V <br /> Program Elernent ESi SIZE SITE TELEPHONE NUMBER <br /> 0 # Seats N,CA CT -11 <br /> Sq. Ft. <br /> # Units <br /> OWNER NAME(30 characters) . <br /> OWNER Address (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORIMATION <br /> HCO <br /> Rec. Health <br /> No.of Service Source of Treatment Population <br /> Program Element Connections Supply Type <br /> Served <br /> ,,eter 4 6FT, <br /> San. Sup. AC SC <br /> F�... ❑ 01 e (1 9 <br />